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Lammers EMJ, Zijlstra JM, Retèl VP, Aleman BMP, van Leeuwen FE, Nijdam A. Effectiveness and Cost-Effectiveness of Survivorship Care for Survivors of Hodgkin Lymphoma (INSIGHT Study): Protocol for a Multicenter Retrospective Cohort Study With a Quasi-Experimental Design. JMIR Res Protoc 2024; 13:e55601. [PMID: 38635308 PMCID: PMC11066749 DOI: 10.2196/55601] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2023] [Revised: 02/14/2024] [Accepted: 02/26/2024] [Indexed: 04/19/2024] Open
Abstract
BACKGROUND Hodgkin lymphoma (HL) occurs at young ages, with the highest incidence between 20 and 40 years. While cure rates have improved to 80%-90% over the past decades, survivors of HL are at substantial risk of late treatment-related complications, such as cardiovascular diseases, breast cancer, severe infections, and hypothyroidism. To reduce morbidity and mortality from late treatment effects, the Dutch Better care after lymphoma, Evaluation of long-term Treatment Effects and screening Recommendations (BETER) consortium developed a survivorship care program for 5-year survivors of HL that includes risk-based screening for and treatment of (risk factors for) late adverse events. Even though several cancer survivorship care programs have been established worldwide, there is a lack of knowledge about their effectiveness in clinical practice. OBJECTIVE The Improving Nationwide Survivorship care Infrastructure and Guidelines after Hodgkin lymphoma Treatment (INSIGHT) study evaluates whether Dutch BETER survivorship care for survivors of HL decreases survivors' burden of disease from late adverse events after HL treatment and associated health care costs and improves their quality of life. METHODS The INSIGHT study is a multicenter retrospective cohort study with a quasi-experimental design and prospective follow-up, embedded in the national BETER survivorship care infrastructure. The first BETER clinics started in 2013-2016 and several other centers started or will start BETER clinics in 2019-2024. This allows us to compare survivors who did and those who did not receive BETER survivorship care in the last decade. Survivors in the intervention group are matched to controls (n=450 per group) based on sex, age at diagnosis (±5 years), age in 2013 (±5 years), and treatment characteristics. The primary outcome is the burden of disease in disability-adjusted life years from cardiovascular disease, breast cancer, severe infections, and hypothyroidism. In a cost-effectiveness analysis, we will assess the cost of BETER survivorship care per averted or gained disability-adjusted life year and quality-adjusted life year. Secondary outcomes are BETER clinic attendance, adherence to screening guidelines, and knowledge and distress about late effects among survivors of HL. Study data are collected from a survivor survey, a general practitioner survey, medical records, and through linkages with national disease registries. RESULTS The study was funded in November 2020 and approved by the institutional review board of the Netherlands Cancer Institute in July 2021. We expect to finalize recruitment by October 2024, data collection by early 2025, and data analysis by May 2025. CONCLUSIONS INSIGHT is the first evaluation of a comprehensive survivorship program using real-world data; it will result in new information on the (cost-)effectiveness of survivorship care in survivors of HL in clinical practice. The results of this study will be used to improve the BETER program where necessary and contribute to more effective evidence-based long-term survivorship care for lymphoma survivors. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) PRR1-10.2196/55601.
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Affiliation(s)
- Eline M J Lammers
- Department of Epidemiology, The Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Josée M Zijlstra
- Department of Hematology, Amsterdam UMC, location Vrije Universiteit, Cancer Center, Amsterdam, Netherlands
| | - Valesca P Retèl
- Department of Health Technology Assessment, The Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Berthe M P Aleman
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Flora E van Leeuwen
- Department of Epidemiology, The Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Annelies Nijdam
- Department of Epidemiology, The Netherlands Cancer Institute, Amsterdam, Netherlands
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Ehrhardt MJ, Liu Q, Mulrooney DA, Rhea IB, Dixon SB, Lucas JT, Sapkota Y, Shelton K, Ness KK, Srivastava DK, McDonald A, Robison LL, Hudson MM, Yasui Y, Armstrong GT. Improved Cardiomyopathy Risk Prediction Using Global Longitudinal Strain and N-Terminal-Pro-B-Type Natriuretic Peptide in Survivors of Childhood Cancer Exposed to Cardiotoxic Therapy. J Clin Oncol 2024; 42:1265-1277. [PMID: 38207238 PMCID: PMC11095874 DOI: 10.1200/jco.23.01796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Revised: 09/27/2023] [Accepted: 10/26/2023] [Indexed: 01/13/2024] Open
Abstract
PURPOSE To leverage baseline global longitudinal strain (GLS) and N-terminal-pro-B-type natriuretic peptide (NT-proBNP) to identify childhood cancer survivors with a normal left ventricular ejection fraction (LVEF) at highest risk of future treatment-related cardiomyopathy. METHODS St Jude Lifetime Cohort participants ≥5 years from diagnosis, at increased risk for cardiomyopathy per the International Guideline Harmonization Group (IGHG), with an LVEF ≥50% on baseline echocardiography (n = 1,483) underwent measurement of GLS (n = 1,483) and NT-proBNP (n = 1,052; 71%). Multivariable Cox regression models estimated hazard ratios (HRs) and 95% CIs for postbaseline cardiomyopathy (modified Common Terminology Criteria for Adverse Events ≥grade 2) incidence in association with echocardiogram-based GLS (≥-18) and/or NT-proBNP (>age-sex-specific 97.5th percentiles). Prediction performance was assessed using AUC in models with and without GLS and NT-proBNP and compared using DeLong's test for IGHG moderate- and high-risk individuals treated with anthracyclines. RESULTS Among survivors (median age, 37.6; range, 10.2-70.4 years), 162 (11.1%) developed ≥grade 2 cardiomyopathy 5.1 (0.7-10.0) years from baseline assessment. The 5-year cumulative incidence of cardiomyopathy for survivors with and without abnormal GLS was, respectively, 7.3% (95% CI, 4.7 to 9.9) versus 4.4% (95% CI, 3.0 to 5.7) and abnormal NT-proBNP was 9.9% (95% CI, 5.8 to 14.1) versus 4.7% (95% CI, 3.2 to 6.2). Among survivors with a normal LVEF, abnormal baseline GLS and NT-proBNP identified anthracycline-exposed, IGHG-defined moderate-/high-risk survivors at a four-fold increased hazard of postbaseline cardiomyopathy (HR, 4.39 [95% CI, 2.46 to 7.83]; P < .001), increasing to a HR of 14.16 (95% CI, 6.45 to 31.08; P < .001) among survivors who received ≥250 mg/m2 of anthracyclines. Six years after baseline, AUCs for individual risk prediction were 0.70 for models with and 0.63 for models without GLS and NT-proBNP (P = .022). CONCLUSION GLS and NT-proBNP should be considered for improved identification of survivors at high risk for future cardiomyopathy.
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Affiliation(s)
- Matthew J. Ehrhardt
- Department of Oncology, St Jude Children's Research Hospital, Memphis, TN
- Department of Epidemiology and Cancer Control, St Jude Children's Research Hospital, Memphis, TN
| | - Qi Liu
- Department of Public Health Sciences, University of Alberta, Edmonton, AB, Canada
| | - Daniel A. Mulrooney
- Department of Oncology, St Jude Children's Research Hospital, Memphis, TN
- Department of Epidemiology and Cancer Control, St Jude Children's Research Hospital, Memphis, TN
| | - Isaac B. Rhea
- Department of Medicine, University of Tennessee Health Science Center, Memphis, TN
| | - Stephanie B. Dixon
- Department of Oncology, St Jude Children's Research Hospital, Memphis, TN
- Department of Epidemiology and Cancer Control, St Jude Children's Research Hospital, Memphis, TN
| | - John T. Lucas
- Department of Radiation Oncology, St Jude Children's Research Hospital, Memphis, TN
| | - Yadav Sapkota
- Department of Epidemiology and Cancer Control, St Jude Children's Research Hospital, Memphis, TN
| | - Kyla Shelton
- Department of Epidemiology and Cancer Control, St Jude Children's Research Hospital, Memphis, TN
| | - Kirsten K. Ness
- Department of Epidemiology and Cancer Control, St Jude Children's Research Hospital, Memphis, TN
| | | | - Aaron McDonald
- Department of Epidemiology and Cancer Control, St Jude Children's Research Hospital, Memphis, TN
| | - Leslie L. Robison
- Department of Epidemiology and Cancer Control, St Jude Children's Research Hospital, Memphis, TN
| | - Melissa M. Hudson
- Department of Oncology, St Jude Children's Research Hospital, Memphis, TN
- Department of Epidemiology and Cancer Control, St Jude Children's Research Hospital, Memphis, TN
| | - Yutaka Yasui
- Department of Epidemiology and Cancer Control, St Jude Children's Research Hospital, Memphis, TN
| | - Gregory T. Armstrong
- Department of Epidemiology and Cancer Control, St Jude Children's Research Hospital, Memphis, TN
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Shuldiner J, Sutradhar R, Lau C, Shah N, Lam E, Ivers N, Nathan PC. Longitudinal adherence to surveillance for late effects of cancer treatment: a population-based study of adult survivors of childhood cancer. CMAJ 2024; 196:E282-E294. [PMID: 38467416 PMCID: PMC10927290 DOI: 10.1503/cmaj.231358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/24/2024] [Indexed: 03/13/2024] Open
Abstract
BACKGROUND Adult survivors of childhood cancer are at elevated risk of morbidity and mortality compared to the general population, but their adherence to lifelong periodic surveillance is suboptimal. We aimed to examine adherence to surveillance guidelines for high-yield tests and identify risk factors for nonadherence in adult survivors of childhood cancer. METHODS In this retrospective, population-based cohort study, we used health care administrative data from Ontario, Canada, to identify adult survivors of childhood cancer diagnosed between 1986 and 2014 who were at elevated risk of therapy-related colorectal cancer, breast cancer, or cardiomyopathy. Using a Poisson regression framework, we assessed longitudinal adherence and predictors of adherence to the Children's Oncology Group surveillance guideline. RESULTS Among 3241 survivors, 327 (10%), 234 (7%), and 3205 (99%) were at elevated risk for colorectal cancer, breast cancer, and cardiomyopathy, respectively. Within these cohorts, only 13%, 6%, and 53% were adherent to recommended surveillance as of February 2020. During a median follow-up of 7.8 years, the proportion of time spent adherent was 14% among survivors at elevated risk for colorectal cancer, 10% for breast cancer, and 43% for cardiomyopathy. Significant predictors of adherence varied across the risk groups, but higher comorbidity was associated with adherence to recommended surveillance. INTERPRETATION Survivors of childhood cancer in Ontario are rarely up to date for recommended surveillance tests. Tailored interventions beyond specialized clinics are needed to improve surveillance adherence.
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Affiliation(s)
- Jennifer Shuldiner
- Women's College Hospital Institute for Health System Solutions and Virtual Care (Shuldiner, Ivers), Women's College Hospital; ICES Central (Sutradhar, Lau); the Hospital for Sick Children Research Institute (Shah, Lam, Nathan); Institute of Health Policy, Management and Evaluation (Ivers, Nathan), and Department of Family and Community Medicine (Ivers), University of Toronto; Division of Hematology/Oncology (Nathan), The Hospital for Sick Children, Toronto, Ont.
| | - Rinku Sutradhar
- Women's College Hospital Institute for Health System Solutions and Virtual Care (Shuldiner, Ivers), Women's College Hospital; ICES Central (Sutradhar, Lau); the Hospital for Sick Children Research Institute (Shah, Lam, Nathan); Institute of Health Policy, Management and Evaluation (Ivers, Nathan), and Department of Family and Community Medicine (Ivers), University of Toronto; Division of Hematology/Oncology (Nathan), The Hospital for Sick Children, Toronto, Ont
| | - Cindy Lau
- Women's College Hospital Institute for Health System Solutions and Virtual Care (Shuldiner, Ivers), Women's College Hospital; ICES Central (Sutradhar, Lau); the Hospital for Sick Children Research Institute (Shah, Lam, Nathan); Institute of Health Policy, Management and Evaluation (Ivers, Nathan), and Department of Family and Community Medicine (Ivers), University of Toronto; Division of Hematology/Oncology (Nathan), The Hospital for Sick Children, Toronto, Ont
| | - Nida Shah
- Women's College Hospital Institute for Health System Solutions and Virtual Care (Shuldiner, Ivers), Women's College Hospital; ICES Central (Sutradhar, Lau); the Hospital for Sick Children Research Institute (Shah, Lam, Nathan); Institute of Health Policy, Management and Evaluation (Ivers, Nathan), and Department of Family and Community Medicine (Ivers), University of Toronto; Division of Hematology/Oncology (Nathan), The Hospital for Sick Children, Toronto, Ont
| | - Emily Lam
- Women's College Hospital Institute for Health System Solutions and Virtual Care (Shuldiner, Ivers), Women's College Hospital; ICES Central (Sutradhar, Lau); the Hospital for Sick Children Research Institute (Shah, Lam, Nathan); Institute of Health Policy, Management and Evaluation (Ivers, Nathan), and Department of Family and Community Medicine (Ivers), University of Toronto; Division of Hematology/Oncology (Nathan), The Hospital for Sick Children, Toronto, Ont
| | - Noah Ivers
- Women's College Hospital Institute for Health System Solutions and Virtual Care (Shuldiner, Ivers), Women's College Hospital; ICES Central (Sutradhar, Lau); the Hospital for Sick Children Research Institute (Shah, Lam, Nathan); Institute of Health Policy, Management and Evaluation (Ivers, Nathan), and Department of Family and Community Medicine (Ivers), University of Toronto; Division of Hematology/Oncology (Nathan), The Hospital for Sick Children, Toronto, Ont
| | - Paul C Nathan
- Women's College Hospital Institute for Health System Solutions and Virtual Care (Shuldiner, Ivers), Women's College Hospital; ICES Central (Sutradhar, Lau); the Hospital for Sick Children Research Institute (Shah, Lam, Nathan); Institute of Health Policy, Management and Evaluation (Ivers, Nathan), and Department of Family and Community Medicine (Ivers), University of Toronto; Division of Hematology/Oncology (Nathan), The Hospital for Sick Children, Toronto, Ont
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Cohen-Cutler S, Kaplan C, Olch A, Wong K, Malvar J, Constine LS, Freyer DR. Impact of Volumetric Dosimetry on the Projected Cost of Radiation-Related Late Effects Screening After Childhood Cancer: A Real-World Cohort Analysis. Oncologist 2023; 28:e784-e792. [PMID: 37284853 PMCID: PMC10485276 DOI: 10.1093/oncolo/oyad136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 04/13/2023] [Indexed: 06/08/2023] Open
Abstract
BACKGROUND Screening guidelines for childhood cancer survivors treated with radiation currently rely on broad anatomic irradiated regions (IR) to determine risk for late effects. However, contemporary radiotherapy techniques use volumetric dosimetry (VD) to define organ-specific exposure, which supports more specific screening recommendations that could be less costly. PATIENTS AND METHODS This was a cross-sectional study of 132 patients treated with irradiation at Children's Hospital Los Angeles from 2000 to 2016. For 5 key organs (cochlea, breast, heart, lung, and colon), radiation exposure was determined retrospectively using both IR and VD methods. Under each method, Children's Oncology Group Long-Term Follow-Up Guidelines were used to identify organs flagged for screening and recommended screening tests. Projected screening costs incurred under each method were computed through age 65 using insurance claims data. RESULTS Median age at the end of treatment was 10.6 years (range, 1.4-20.4). Brain tumor was the most common diagnosis (45%) and head/brain the most common irradiated region (61%). For all 5 organs, use of VD rather than IR resulted in fewer recommended screening tests. This led to average cumulative estimated savings of $3769 (P = .099), with significant savings in patients with CNS tumors (P = .012). Among patients with savings, average savings were $9620 per patient (P = .016) and significantly more likely for females than males (P = .027). CONCLUSION Use of VD to enhance precision of guideline-based screening for radiation-related late effects permits fewer recommended screening tests and generates cost-savings.
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Affiliation(s)
- Sally Cohen-Cutler
- Cancer and Blood Disease Institute, Children’s Hospital Los Angeles, Los Angeles, CA, USA
- Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Cameron Kaplan
- Department of Medicine, Gehr Family Center for Health Systems Science and Innovation, University of Southern California, Los Angeles, CA, USA
| | - Arthur Olch
- Radiation Oncology Program, Cancer and Blood Disease Institute, Children’s Hospital Los Angeles, Los Angeles, CA, USA
- Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Kenneth Wong
- Radiation Oncology Program, Cancer and Blood Disease Institute, Children’s Hospital Los Angeles, Los Angeles, CA, USA
- Department of Radiation Oncology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Jemily Malvar
- Cancer and Blood Disease Institute, Children’s Hospital Los Angeles, Los Angeles, CA, USA
| | - Louis S Constine
- Departments of Radiation Oncology and Pediatrics, James P Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, NY, USA
| | - David R Freyer
- Cancer and Blood Disease Institute, Children’s Hospital Los Angeles, Los Angeles, CA, USA
- Department of Pediatrics and Population and Public Health Sciences, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
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Horan MR, Srivastava DK, Bhakta N, Ehrhardt MJ, Brinkman TM, Baker JN, Yasui Y, Krull KR, Ness KK, Robison LL, Hudson MM, Huang IC. Determinants of health-related quality-of-life in adult survivors of childhood cancer: integrating personal and societal values through a health utility approach. EClinicalMedicine 2023; 58:101921. [PMID: 37090443 PMCID: PMC10114517 DOI: 10.1016/j.eclinm.2023.101921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 03/05/2023] [Accepted: 03/07/2023] [Indexed: 04/25/2023] Open
Abstract
Background Childhood cancer survivors are at elevated risk for poor health-related quality-of-life (HRQOL). Identification of potentially modifiable risk factors associated with HRQOL is needed to inform survivorship care. Methods Participants included 4294 adult childhood cancer survivors from the St. Jude Lifetime Cohort Study who completed a survey and clinical assessment at entry into the survivorship cohort (baseline) and follow-up (median interval: 4.3 years) between 2007 and 2019. The SF-6D compared utility-based HRQOL of survivors to an independent sample from the U.S. Medical Expenditures Panel Survey. Chronic health conditions (CHCs) were graded using modified Common Terminology Criteria for Adverse Events. General linear models examined cross-sectional and temporal associations of HRQOL with CHC burden (total and by organ-system), adjusting for potential risk factors. Findings Survivors reported poorer HRQOL compared to the general population (effect size [d] = -0.343). In cross-sectional analyses at baseline, significant non-demographic risk factors included higher total CHC burden (driven by more severe cardiovascular [d = -0.119, p = 0.002], endocrine [d = -0.112, p = 0.001], gastrointestinal [d = -0.226, p < 0.001], immunologic [d = -0.168, p = 0.035], neurologic [d = -0.388, p < 0.001], pulmonary [d = -0.132, p = 0.003] CHCs), public (d = -0.503, p < 0.001) or no health insurance (d = -0.123, p = 0.007), current smoking (d = -0.270, p < 0.001), being physically inactive (d = -0.129, p < 0.001), ever using illicit drugs (d = -0.235, p < 0.001), and worse diet quality (d = -0.004, p = 0.016). In temporal analyses, poorer utility-based HRQOL at follow-up was associated with risk factors at baseline, including higher total CHC burden (driven by cardiovascular [d = -0.152, p = 0.002], endocrine [d = -0.092, p = 0.047], musculoskeletal [d = -0.160, p = 0.016], neurologic [d = -0.318, p < 0.001] CHCs), public (d = -0.415, p < 0.001) or no health insurance (d = -0.161, p = 0.007), current smoking (d = -0.218, p = 0.001), and ever using illicit drugs (d = -0.217, p < 0.001). Interpretation Adult survivors report worse utility-based HRQOL than the general population, and potentially modifiable risk factors were associated with HRQOL. Interventions to prevent the early onset of CHCs, promote healthy lifestyle, and ensure access to health insurance in the early survivorship stage may provide opportunities to improve HRQOL. Funding The research reported in this manuscript was supported by the U.S. National Cancer Institute under award numbers U01CA195547 (Hudson/Ness), R01CA238368 (Huang/Baker), R01CA258193 (Huang/Yasui), R01CA270157 (Bhakta/Yasui), and T32CA225590 (Krull). The content is solely the responsibility of the authors and does not necessarily represent the official views of the funding agencies.
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Affiliation(s)
- Madeline R. Horan
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Deo Kumar Srivastava
- Department of Biostatistics, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Nickhill Bhakta
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Matthew J. Ehrhardt
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN, USA
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Tara M. Brinkman
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN, USA
- Department of Psychology and Biobehavioral Sciences, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Justin N. Baker
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Yutaka Yasui
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Kevin R. Krull
- Department of Psychology and Biobehavioral Sciences, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Kirsten K. Ness
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Leslie L. Robison
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Melissa M. Hudson
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN, USA
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - I-Chan Huang
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN, USA
- Corresponding author. Department of Epidemiology & Cancer Control, St. Jude Children's Research Hospital, 262 Danny Thomas Place, MS735, Memphis, TN, 38105, USA.
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Joolharzadeh P, Rodriguez M, Zaghlol R, Pedersen LN, Jimenez J, Bergom C, Mitchell JD. Recent Advances in Serum Biomarkers for Risk Stratification and Patient Management in Cardio-Oncology. Curr Cardiol Rep 2023; 25:133-146. [PMID: 36790618 PMCID: PMC9930715 DOI: 10.1007/s11886-022-01834-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/31/2022] [Indexed: 02/16/2023]
Abstract
PURPOSE OF REVIEW Following significant advancements in cancer therapeutics and survival, the risk of cancer therapy-related cardiotoxicity (CTRC) is increasingly recognized. With ongoing efforts to reduce cardiovascular morbidity and mortality in cancer patients and survivors, cardiac biomarkers have been studied for both risk stratification and monitoring during and after therapy to detect subclinical disease. This article will review the utility for biomarker use throughout the cancer care continuum. RECENT FINDINGS A recent meta-analysis shows utility for troponin in monitoring patients at risk for CTRC during cancer therapy. The role for natriuretic peptides is less clear but may be useful in patients receiving proteasome inhibitors. Early studies explore use of myeloperoxidase, growth differentiation factor 15, galectin 3, micro-RNA, and others as novel biomarkers in CTRC. Biomarkers have potential to identify subclinical CTRC and may reveal opportunities for early intervention. Further research is needed to elucidate optimal biomarkers and surveillance strategies.
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Affiliation(s)
- Pouya Joolharzadeh
- General Medical Sciences, Washington University School of Medicine, St. Louis, MO, USA
| | - Mario Rodriguez
- Cardiovascular Division, Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA
- Cardio-Oncology Center of Excellence, Washington University School of Medicine, St. Louis, MO, USA
| | - Raja Zaghlol
- Cardiovascular Division, Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA
- Cardio-Oncology Center of Excellence, Washington University School of Medicine, St. Louis, MO, USA
| | - Lauren N Pedersen
- Cardio-Oncology Center of Excellence, Washington University School of Medicine, St. Louis, MO, USA
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, USA
| | - Jesus Jimenez
- Cardiovascular Division, Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA
- Cardio-Oncology Center of Excellence, Washington University School of Medicine, St. Louis, MO, USA
| | - Carmen Bergom
- Cardio-Oncology Center of Excellence, Washington University School of Medicine, St. Louis, MO, USA
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, USA
- Alvin J. Siteman Cancer Center, Washington University in St. Louis, St. Louis, MO, USA
| | - Joshua D Mitchell
- Cardiovascular Division, Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA.
- Cardio-Oncology Center of Excellence, Washington University School of Medicine, St. Louis, MO, USA.
- Alvin J. Siteman Cancer Center, Washington University in St. Louis, St. Louis, MO, USA.
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Ehrhardt MJ, Leerink JM, Mulder RL, Mavinkurve-Groothuis A, Kok W, Nohria A, Nathan PC, Merkx R, de Baat E, Asogwa OA, Skinner R, Wallace H, Lieke Feijen EAM, de Ville de Goyet M, Prasad M, Bárdi E, Pavasovic V, van der Pal H, Fresneau B, Demoor-Goldschmidt C, Hennewig U, Steinberger J, Plummer C, Chen MH, Teske AJ, Haddy N, van Dalen EC, Constine LS, Chow EJ, Levitt G, Hudson MM, Kremer LCM, Armenian SH. Systematic review and updated recommendations for cardiomyopathy surveillance for survivors of childhood, adolescent, and young adult cancer from the International Late Effects of Childhood Cancer Guideline Harmonization Group. Lancet Oncol 2023; 24:e108-e120. [PMID: 37052966 DOI: 10.1016/s1470-2045(23)00012-8] [Citation(s) in RCA: 28] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 12/07/2022] [Accepted: 01/10/2023] [Indexed: 02/16/2023]
Abstract
Survivors of childhood, adolescent, and young adult cancer, previously treated with anthracycline chemotherapy (including mitoxantrone) or radiotherapy in which the heart was exposed, are at increased risk of cardiomyopathy. Symptomatic cardiomyopathy is typically preceded by a series of gradually progressive, asymptomatic changes in structure and function of the heart that can be ameliorated with treatment, prompting specialist organisations to endorse guidelines on cardiac surveillance in at-risk survivors of cancer. In 2015, the International Late Effects of Childhood Cancer Guideline Harmonization Group compiled these guidelines into a uniform set of recommendations applicable to a broad spectrum of clinical environments with varying resource availabilities. Since then, additional studies have provided insight into dose thresholds associated with a risk of asymptomatic and symptomatic cardiomyopathy, have characterised risk over time, and have established the cost-effectiveness of different surveillance strategies. This systematic Review and guideline provides updated recommendations based on the evidence published up to September, 2020.
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de Baat EC, van Dalen EC, Mulder RL, Hudson MM, Ehrhardt MJ, Engels FK, Feijen EAM, Grotenhuis HB, Leerink JM, Kapusta L, Kaspers GJL, Merkx R, Mertens L, Skinner R, Tissing WJE, de Vathaire F, Nathan PC, Kremer LCM, Mavinkurve-Groothuis AMC, Armenian S. Primary cardioprotection with dexrazoxane in patients with childhood cancer who are expected to receive anthracyclines: recommendations from the International Late Effects of Childhood Cancer Guideline Harmonization Group. THE LANCET. CHILD & ADOLESCENT HEALTH 2022; 6:885-894. [PMID: 36174614 DOI: 10.1016/s2352-4642(22)00239-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Revised: 07/24/2022] [Accepted: 08/01/2022] [Indexed: 06/16/2023]
Abstract
Survivors of childhood cancer are at risk of anthracycline-induced cardiotoxicity, which might be prevented by dexrazoxane. However, concerns exist about the safety of dexrazoxane, and little guidance is available on its use in children. To facilitate global consensus, a working group within the International Late Effects of Childhood Cancer Guideline Harmonization Group reviewed the existing literature and used evidence-based methodology to develop a guideline for dexrazoxane administration in children with cancer who are expected to receive anthracyclines. Recommendations were made in consideration of evidence supporting the balance of potential benefits and harms, and clinical judgement by the expert panel. Given the dose-dependent risk of anthracycline-induced cardiotoxicity, we concluded that the benefits of dexrazoxane probably outweigh the risk of subsequent neoplasms when the cumulative doxorubicin or equivalent dose is at least 250 mg/m2 (moderate recommendation). No recommendation could be formulated for cumulative doxorubicin or equivalent doses of lower than 250 mg/m2, due to insufficient evidence to determine whether the risk of cardiotoxicity outweighs the possible risk of subsequent neoplasms. Further research is encouraged to determine the long-term efficacy and safety of dexrazoxane in children with cancer.
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Affiliation(s)
- Esmée C de Baat
- Princess Máxima Center for Pediatric Oncology, Utrecht, Netherlands.
| | | | - Renée L Mulder
- Princess Máxima Center for Pediatric Oncology, Utrecht, Netherlands
| | - Melissa M Hudson
- Department of Oncology, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Matthew J Ehrhardt
- Department of Oncology, St Jude Children's Research Hospital, Memphis, TN, USA
| | | | | | | | - Jan M Leerink
- Princess Máxima Center for Pediatric Oncology, Utrecht, Netherlands; Amsterdam University Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - Livia Kapusta
- Department of Pediatrics, Amalia Children's Hospital, Radboud University Medical Center, Nijmegen, Netherlands; Pediatric Cardiology Unit, Department of Pediatrics, Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Centre affiliated to the Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Gertjan J L Kaspers
- Princess Máxima Center for Pediatric Oncology, Utrecht, Netherlands; Department of Pediatric Oncology, Emma Children's Hospital, Amsterdam University Medical Center, Vrije Universiteit Amsterdam, Netherlands
| | - Remy Merkx
- Department of Medical Imaging, Radboud University Medical Center, Nijmegen, Netherlands
| | - Luc Mertens
- The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Roderick Skinner
- Department of Paediatric and Adolescent Haematology and Oncology, Great North Children's Hospital, Newcastle upon Tyne, UK; Translational and Clinical Research Institute, Newcastle University Centre for Cancer, Newcastle University, Newcastle upon Tyne, UK
| | - Wim J E Tissing
- Princess Máxima Center for Pediatric Oncology, Utrecht, Netherlands
| | | | - Paul C Nathan
- The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Leontien C M Kremer
- Princess Máxima Center for Pediatric Oncology, Utrecht, Netherlands; Wilhelmina Children's Hospital-University Medical Center Utrecht, Utrecht, Netherlands; Department of Pediatric Oncology, Emma Children's Hospital, Amsterdam University Medical Center, University of Amsterdam, Netherlands
| | | | - Saro Armenian
- Department of Population Sciences, City of Hope National Medical Center, Duarte, CA, USA
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9
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van Kalsbeek RJ, Korevaar JC, Rijken M, Haupt R, Muraca M, Kepák T, Kepakova K, Blondeel A, Boes S, Frederiksen LE, Essiaf S, Winther JF, Hermens RPMG, Kienesberger A, Loonen JJ, Michel G, Mulder RL, O'Brien KB, van der Pal HJH, Pluijm SMF, Roser K, Skinner R, Renard M, Uyttebroeck A, Follin C, Hjorth L, Kremer LCM. Evaluating the feasibility, effectiveness and costs of implementing person-centred follow-up care for childhood cancer survivors in four European countries: the PanCareFollowUp Care prospective cohort study protocol. BMJ Open 2022; 12:e063134. [PMID: 36396317 PMCID: PMC9677022 DOI: 10.1136/bmjopen-2022-063134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Long-term survival after childhood cancer often comes at the expense of late, adverse health conditions. However, survivorship care is frequently not available for adult survivors in Europe. The PanCareFollowUp Consortium therefore developed the PanCareFollowUp Care Intervention, an innovative person-centred survivorship care model based on experiences in the Netherlands. This paper describes the protocol of the prospective cohort study (Care Study) to evaluate the feasibility and the health economic, clinical and patient-reported outcomes of implementing PanCareFollowUp Care as usual care in four European countries. METHODS AND ANALYSIS In this prospective, longitudinal cohort study with at least 6 months of follow-up, 800 childhood cancer survivors will receive the PanCareFollowUp Care Intervention across four study sites in Belgium, Czech Republic, Italy and Sweden, representing different healthcare systems. The PanCareFollowUp Care Intervention will be evaluated according to the Reach, Effectiveness, Adoption, Implementation and Maintenance framework. Clinical and research data are collected through questionnaires, a clinic visit for multiple medical assessments and a follow-up call. The primary outcome is empowerment, assessed with the Health Education Impact Questionnaire. A central data centre will perform quality checks, data cleaning and data validation, and provide support in data analysis. Multilevel models will be used for repeated outcome measures, with subgroup analysis, for example, by study site, attained age, sex or diagnosis. ETHICS AND DISSEMINATION This study will be conducted in accordance with the guidelines of Good Clinical Practice and the Declaration of Helsinki. The study protocol has been reviewed and approved by all relevant ethics committees. The evidence and insights gained by this study will be summarised in a Replication Manual, also including the tools required to implement the PanCareFollowUp Care Intervention in other countries. This Replication Manual will become freely available through PanCare and will be disseminated through policy and press releases. TRIAL REGISTRATION NUMBER Netherlands Trial Register (NL8918; https://www.trialregister.nl/trial/8918).
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Affiliation(s)
| | - Joke C Korevaar
- Netherlands Institute for Health Services Research (NIVEL), Utrecht, The Netherlands
| | - Mieke Rijken
- Netherlands Institute for Health Services Research (NIVEL), Utrecht, The Netherlands
- Department of Health and Social Care Management, University of Eastern Finland-Kuopio Campus, Kuopio, Finland
| | - Riccardo Haupt
- DOPO Clinic, Department of Hematology/Oncology, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Monica Muraca
- DOPO Clinic, Department of Hematology/Oncology, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Tomáš Kepák
- International Clinical Research Centre (FNUSA-ICRC) at St Anne's University Hospital, Masaryk University Faculty of Medicine, Brno, Czech Republic
| | - Katerina Kepakova
- International Clinical Research Centre (FNUSA-ICRC) at St Anne's University Hospital, Masaryk University Faculty of Medicine, Brno, Czech Republic
| | - Anne Blondeel
- European Society for Pediatric Oncology (SIOP Europe), Brussels, Belgium
| | - Stefan Boes
- Department of Health Sciences and Medicine, University of Lucerne, Lucerne, Switzerland
| | - Line E Frederiksen
- Childhood Cancer Research Group, Danish Cancer Society Research Center, Copenhagen, Denmark
| | - Samira Essiaf
- European Society for Pediatric Oncology (SIOP Europe), Brussels, Belgium
| | - Jeanette F Winther
- Childhood Cancer Research Group, Danish Cancer Society Research Center, Copenhagen, Denmark
- Department of Clinical Medicine and Faculty of Health, Aarhus Universitet, Aarhus, Denmark
| | - Rosella P M G Hermens
- Scientific Institute for Quality of Healthcare (IQ Healthcare), Radboudumc, Nijmegen, The Netherlands
| | | | | | - Gisela Michel
- Department of Health Sciences and Medicine, University of Lucerne, Lucerne, Switzerland
| | - Renée L Mulder
- Princess Maxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | | | - Helena J H van der Pal
- Princess Maxima Center for Pediatric Oncology, Utrecht, The Netherlands
- PanCare, Bussum, The Netherlands
| | - Saskia M F Pluijm
- Princess Maxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | - Katharina Roser
- Department of Health Sciences and Medicine, University of Lucerne, Lucerne, Switzerland
| | - Roderick Skinner
- Wolfson Childhood Cancer Research Centre, Newcastle University Centre for Cancer, Newcastle upon Tyne, UK
- Royal Victoria Infirmary, Great North Children's Hospital, Newcastle upon Tyne, UK
| | - Marleen Renard
- Department of Paediatric Haematology and Oncology, KU Leuven, University Hospitals Leuven, Leuven, Belgium
| | - Anne Uyttebroeck
- Department of Paediatric Haematology and Oncology, KU Leuven, University Hospitals Leuven, Leuven, Belgium
| | - Cecilia Follin
- Department of Clinical Sciences Lund, Oncology, Lund University, Skane University Hospital, Lund, Sweden
| | - Lars Hjorth
- Department of Clinical Sciences Lund, Paediatrics, Lund University, Skane University Hospital, Lund, Sweden
| | - Leontien C M Kremer
- Princess Maxima Center for Pediatric Oncology, Utrecht, The Netherlands
- Department of Paediatrics, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
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10
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Baldassarre LA, Ganatra S, Lopez-Mattei J, Yang EH, Zaha VG, Wong TC, Ayoub C, DeCara JM, Dent S, Deswal A, Ghosh AK, Henry M, Khemka A, Leja M, Rudski L, Villarraga HR, Liu JE, Barac A, Scherrer-Crosbie M. Advances in Multimodality Imaging in Cardio-Oncology: JACC State-of-the-Art Review. J Am Coll Cardiol 2022; 80:1560-1578. [PMID: 36229093 DOI: 10.1016/j.jacc.2022.08.743] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Revised: 07/29/2022] [Accepted: 08/01/2022] [Indexed: 11/07/2022]
Abstract
The population of patients with cancer is rapidly expanding, and the diagnosis and monitoring of cardiovascular complications greatly rely on imaging. Numerous advances in the field of cardio-oncology and imaging have occurred in recent years. This review presents updated and practical approaches for multimodality cardiovascular imaging in the cardio-oncology patient and provides recommendations for imaging to detect the myriad of adverse cardiovascular effects associated with antineoplastic therapy, such as cardiomyopathy, atherosclerosis, vascular toxicity, myocarditis, valve disease, and cardiac masses. Uniquely, we address the role of cardiovascular imaging in patients with pre-existing cardiomyopathy, pregnant patients, long-term survivors, and populations with limited resources. We also address future avenues of investigation and opportunities for artificial intelligence applications in cardio-oncology imaging. This review provides a uniform practical approach to cardiovascular imaging for patients with cancer.
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Affiliation(s)
- Lauren A Baldassarre
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Sarju Ganatra
- Cardio-Oncology and Cardiac MRI Program, Division of Cardiovascular Medicine, Department of Medicine, Lahey Hospital and Medical Center, Beth Israel Lahey Health, Burlington, Massachusetts, USA
| | - Juan Lopez-Mattei
- Cardiovascular Imaging Program, Department of Cardiovascular Medicine, Lee Health, Fort Myers, Florida, USA
| | - Eric H Yang
- UCLA Cardio-Oncology Program, Division of Cardiology, Department of Medicine, University of California, Los Angeles, California, USA
| | - Vlad G Zaha
- Cardio-Oncology Program, Harold C. Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas, Texas, USA; Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Timothy C Wong
- UPMC Cardiovascular Magnetic Resonance Center, Division of Cardiology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Chadi Ayoub
- Division of Cardiovascular Medicine, Mayo Clinic, Scottsdale, Arizona, USA
| | - Jeanne M DeCara
- Cardio-Oncology Program, Section of Cardiology, Department of Medicine, University of Chicago, Chicago, Illinois, USA
| | - Susan Dent
- Duke Cancer Institute, Department of Medicine, Duke University, Durham, North Carolina, USA
| | - Anita Deswal
- Department of Cardiology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Arjun K Ghosh
- Cardio-Oncology Service, Barts Heart Centre, St Bartholomew's Hospital, London, United Kingdom; Cardio-Oncology Service, University College London Hospital and Hatter Cardiovascular Institute, London, United Kingdom
| | - Mariana Henry
- Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
| | - Abhishek Khemka
- Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Monika Leja
- Cardio-Oncology Program, Department of Cardiovascular Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Lawrence Rudski
- Azrieli Heart Center, Department of Medicine, Jewish General Hospital, McGill University, Montréal, Québec, Canada
| | - Hector R Villarraga
- Department of Cardiovascular Diseases, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Jennifer E Liu
- Cardiology Service, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Ana Barac
- Medstar Heart and Vascular Institute, Georgetown University, Washington, DC, USA; Cardiovascular Branch, Division of Intramural Research, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Marielle Scherrer-Crosbie
- Division of Cardiology, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA.
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11
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Aziz-Bose R, Margossian R, Ames BL, Moss K, Ehrhardt MJ, Armenian SH, Yock TI, Nekhlyudov L, Williams D, Hudson M, Nohria A, Kenney LB. Delphi Panel Consensus Recommendations for Screening and Managing Childhood Cancer Survivors at Risk for Cardiomyopathy. JACC CardioOncol 2022; 4:354-367. [PMID: 36213355 PMCID: PMC9537072 DOI: 10.1016/j.jaccao.2022.05.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Revised: 04/29/2022] [Accepted: 05/06/2022] [Indexed: 11/18/2022] Open
Abstract
Background Cardiomyopathy is a leading cause of late morbidity and mortality in childhood cancer survivors (CCS). Evidence-based guidelines recommend risk-stratified screening for cardiomyopathy, but the management approach for abnormalities detected when screening asymptomatic young adult CCS is poorly defined. Objectives The aims of this study were to build upon existing guidelines by describing the expert consensus–based cardiomyopathy screening practices, management approach, and clinical rationale for the management of young adult CCS with screening-detected abnormalities and to identify areas of controversy in practice. Methods A multispecialty Delphi panel of 40 physicians with expertise in cancer survivorship completed 3 iterative rounds of semi-open-ended questionnaires regarding their approaches to the management of asymptomatic young adult CCS at risk for cardiomyopathy (screening practices, referrals, cardiac testing, laboratory studies, medications). Consensus was defined as ≥90% panelist agreement with recommendation. Results The response rate was 100% for all 3 rounds. Panelists reached consensus on the timing and frequency of echocardiographic screening for anthracycline-associated cardiomyopathy, monitoring during pregnancy, laboratory testing for modifiable cardiac risk factors, and referral to cardiology for ejection fraction ≤50% or preserved ejection fraction with diastolic dysfunction. Controversial areas (<75% agreement) included chest radiation dose threshold to merit screening, indications for advanced cardiac imaging and cardiac serum biomarkers for follow-up of abnormal echocardiographic findings, and medical management of asymptomatic left ventricular systolic dysfunction. Conclusions Expert practice is largely consistent with existing risk-based screening guidelines. Some recommendations for managing abnormalities detected on screening echocardiography remain controversial. The rationale offered by experts for divergent approaches may help guide clinical decisions in the absence of guidelines specific to young adult CCS.
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Affiliation(s)
- Rahela Aziz-Bose
- Dana-Farber Cancer Institute, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Address for correspondence: Dr Rahela Aziz-Bose, Dana-Farber Cancer Institute, SW 311, 450 Brookline Avenue, Boston, Massachusetts 02215, USA. @DrN_CancerPCP
| | - Renee Margossian
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Cardiology, Boston Children’s Hospital, Boston, Massachusetts, USA
| | - Bethany L. Ames
- Geisel School of Medicine at Dartmouth, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - Kerry Moss
- Connecticut Children’s Hospital, Hartford, Connecticut, USA
| | - Matthew J. Ehrhardt
- Department of Oncology, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
- Department of Epidemiology and Cancer Control, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
| | - Saro H. Armenian
- Department of Pediatrics and Population Sciences, City of Hope, Duarte, California, USA
| | - Torunn I. Yock
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Larissa Nekhlyudov
- Dana-Farber Cancer Institute, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - David Williams
- Dana-Farber Cancer Institute, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Melissa Hudson
- Department of Oncology, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
- Department of Epidemiology and Cancer Control, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
| | - Anju Nohria
- Dana-Farber Cancer Institute, Boston, Massachusetts, USA
- Adult Survivorship Program, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
- Cardiovascular Division, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Lisa B. Kenney
- Dana-Farber Cancer Institute, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
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12
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Abstract
PURPOSE OF REVIEW Successful treatment of cancer can be hampered by the attendant risk of cardiotoxicity, manifesting as cardiomyopathy, left ventricle systolic dysfunction and, in some cases, heart failure. This risk can be mitigated if the injury to the heart is detected before the onset to irreversible cardiac impairment. The gold standard for cardiac imaging in cardio-oncology is echocardiography. Despite improvements in the application of this modality, it is not typically sensitive to sub-clinical or early-stage dysfunction. We identify in this review some emerging tracers for detecting incipient cardiotoxicity by positron emission tomography (PET). RECENT FINDINGS Vectors labeled with positron-emitting radionuclides (e.g., carbon-11, fluorine-18, gallium-68) are now available to study cardiac function, metabolism, and tissue repair in preclinical models. Many of these probes are highly sensitive to early damage, thereby potentially addressing the limitations of current imaging approaches, and show promise in preliminary clinical evaluations. The overlapping pathophysiology between cardiotoxicity and heart failure significantly expands the number of imaging tools available to cardio-oncology. This is highlighted by the emergence of radiolabeled probes targeting fibroblast activation protein (FAP) for sensitive detection of dysregulated healing process that underpins adverse cardiac remodeling. The growth of PET scanner technology also creates an opportunity for a renaissance in metabolic imaging in cardio-oncology research.
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Affiliation(s)
- James M. Kelly
- Division of Radiopharmaceutical Sciences and Molecular Imaging Innovations Institute (MI3), Weill Cornell Medicine, Belfer Research Building, Room BB-1604, 413 East 69th St, New York, NY 10021 USA
- Citigroup Biomedical Imaging Center, Weill Cornell Medicine, New York, NY 10021 USA
| | - John W. Babich
- Division of Radiopharmaceutical Sciences and Molecular Imaging Innovations Institute (MI3), Weill Cornell Medicine, Belfer Research Building, Room BB-1604, 413 East 69th St, New York, NY 10021 USA
- Citigroup Biomedical Imaging Center, Weill Cornell Medicine, New York, NY 10021 USA
- Sandra and Edward Meyer Cancer Center, Weill Cornell Medicine, New York, NY 10021 USA
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13
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Noyd DH, Berkman A, Howell C, Power S, Kreissman SG, Landstrom AP, Khouri M, Oeffinger KC, Kibbe WA. Leveraging Clinical Informatics Tools to Extract Cumulative Anthracycline Exposure, Measure Cardiovascular Outcomes, and Assess Guideline Adherence for Children With Cancer. JCO Clin Cancer Inform 2021; 5:1062-1075. [PMID: 34714665 PMCID: PMC9848538 DOI: 10.1200/cci.21.00099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
PURPOSE Cardiovascular disease is a significant cause of late morbidity and mortality in survivors of childhood cancer. Clinical informatics tools could enhance provider adherence to echocardiogram guidelines for early detection of late-onset cardiomyopathy. METHODS Cancer registry data were linked to electronic health record data. Structured query language facilitated the construction of anthracycline-exposed cohorts at a single institution. Primary outcomes included the data quality from automatic anthracycline extraction, sensitivity of International Classification of Disease coding for heart failure, and adherence to echocardiogram guideline recommendations. RESULTS The final analytic cohort included 385 pediatric oncology patients diagnosed between July 1, 2013, and December 31, 2018, among whom 194 were classified as no anthracycline exposure, 143 had low anthracycline exposure (< 250 mg/m2), and 48 had high anthracycline exposure (≥ 250 mg/m2). Manual review of anthracycline exposure was highly concordant (95%) with the automatic extraction. Among the unexposed group, 15% had an anthracycline administered at an outside institution not captured by standard query language coding. Manual review of echocardiogram parameters and clinic notes yielded a sensitivity of 75%, specificity of 98%, and positive predictive value of 68% for International Classification of Disease coding of heart failure. For patients with anthracycline exposure, 78.5% (n = 62) were adherent to guideline recommendations for echocardiogram surveillance. There were significant association with provider adherence and race and ethnicity (P = .047), and 50% of patients with Spanish as their primary language were adherent compared with 90% of patients with English as their primary language (P = .003). CONCLUSION Extraction of treatment exposures from the electronic health record through clinical informatics and integration with cancer registry data represents a feasible approach to assess cardiovascular disease outcomes and adherence to guideline recommendations for survivors.
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Affiliation(s)
- David H. Noyd
- Department of Pediatrics, The University
of Oklahoma Health Sciences Center, Oklahoma City, OK,Department of Pediatrics, Duke University
Medical Center, Durham, NC,David H. Noyd, MD, MPH, 1200 Children's Ave, A2-14702,
Oklahoma City, OK 73104; e-mail:
| | - Amy Berkman
- Department of Pediatrics, Duke University
Medical Center, Durham, NC
| | | | | | - Susan G. Kreissman
- Department of Pediatrics, The University
of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - Andrew P. Landstrom
- Division of Cardiology and Department of
Cell Biology, Department of Pediatrics, Duke University Medical Center, Durham,
NC
| | - Michel Khouri
- Department of Medicine, Duke University
Medical Center, Durham, NC
| | - Kevin C. Oeffinger
- Duke Cancer Institute, Durham, NC,Department of Medicine, Duke University
Medical Center, Durham, NC
| | - Warren A. Kibbe
- Duke Cancer Institute, Durham, NC,Department of Biostatistics and
Bioinformatics, Duke University, Durham, NC
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14
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Benedict C, Wang J, Reppucci M, Schleien CL, Fish JD. Cost of survivorship care and adherence to screening-aligning the priorities of health care systems and survivors. Transl Behav Med 2021; 11:132-142. [PMID: 31907549 DOI: 10.1093/tbm/ibz182] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
Childhood cancer survivors (CCS) experience significant morbidity due to treatment- related late effects and benefit from late-effects surveillance. Adherence to screening recommendations is suboptimal. Survivorship care programs often struggle with resource limitations and may benefit from understanding institution-level financial outcomes associated with patient adherence to justify programmatic development and growth. The purpose of this study is to examine how CCS adherence to screening recommendations relates to the cost of care, insurance status, and institution-level financial outcomes. A retrospective chart review of 286 patients, followed in a structured survivorship program, assessed adherence to the Children's Oncology Group follow-up guidelines by comparing recommended versus performed screening procedures for each patient. Procedure cost estimates were based on insurance status. Institutional profit margins and profit opportunity loss were calculated. Bivariate statistics tested adherent versus nonadherent subgroup differences on cost variables. A generalized linear model predicted the likelihood of adherence based on cost of recommended procedures, controlling for age, gender, race, and insurance. Adherence to recommended surveillance procedures was 50.2%. Nonadherence was associated with higher costs of recommended screening procedures compared to the adherent group estimates ($2,469.84 vs. $1,211.44). Failure to perform the recommended tests resulted in no difference in reimbursement to the health system between groups ($1,249.63 vs. $1,211.08). For the nonadherent group, this represented $1,055.13 in "lost profit opportunity" per visit for patients, which totaled $311,850 in lost profit opportunity due to nonadherence in this subgroup. In the final model, nonadherence was related to higher cost of recommended procedures (p < .0001), older age at visit (p = .04), Black race (p = .02), and government-sponsored insurance (p = .03). Understanding institutional financial outcomes related to patient adherence may help inform survivorship care programs and resource allocation. Potential financial burden to patients associated with complex care recommendations is also warranted.
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Affiliation(s)
| | - Jason Wang
- Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, USA.,Feinstein Institute for Medical Research, Northwell Health, Manhasset, NY, USA
| | - Marina Reppucci
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Charles L Schleien
- Division of Pediatric Hematology/Oncology and Stem Cell Transplantation, Cohen Children's Medical Center, Northwell Health, New Hyde Park, NY, USA.,Department of Pediatrics, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, USA
| | - Jonathan D Fish
- Division of Pediatric Hematology/Oncology and Stem Cell Transplantation, Cohen Children's Medical Center, Northwell Health, New Hyde Park, NY, USA.,Department of Pediatrics, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, USA
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15
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Refining the 10-Year Prediction of Left Ventricular Systolic Dysfunction in Long-Term Survivors of Childhood Cancer. JACC: CARDIOONCOLOGY 2021; 3:62-72. [PMID: 34396306 PMCID: PMC8352242 DOI: 10.1016/j.jaccao.2020.11.013] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Accepted: 11/11/2020] [Indexed: 12/28/2022]
Abstract
Background In childhood cancer survivors (CCS) at risk for heart failure, echocardiographic surveillance recommendations are currently based on anthracyclines and chest-directed radiotherapy dose. Whether the ejection fraction (EF) measured at an initial surveillance echocardiogram can refine these recommendations is unknown. Objectives The purpose of this study was to assess the added predictive value of EF at >5 years after cancer diagnosis to anthracyclines and chest-directed radiotherapy dose in CCS, for the development of left ventricular dysfunction with an ejection fraction <40% (LVD40). Methods Echocardiographic surveillance was performed in 299 CCS from the Emma Children’s Hospital in the Netherlands. Cox regression models were built including cardiotoxic cancer treatment exposures with and without EF to estimate the probability of LVD40 at 10-year follow-up. Calibration, discrimination, and reclassification were assessed. Results were externally validated in 218 CCS. Results Cumulative incidences of LVD40 at 10-year follow-up were 3.7% and 3.6% in the derivation and validation cohort, respectively. The addition of EF resulted in an integrated area under the curve increase from 0.74 to 0.87 in the derivation cohort and from 0.72 to 0.86 in the validation cohort (likelihood ratio p < 0.001). Reclassification of CCS without LVD40 improved significantly (noncase continuous net reclassification improvement 0.50; 95% confidence interval [CI]: 0.40 to 0.60). A predicted LVD40 probability ≤3%, representing 75% of the CCS, had a negative predictive value of 99% (95% CI: 98% to 100%) for LVD40 within 10 years. However, patients with midrange EF (40% to 49%) at initial screening had an incidence of LVD40 of 11% and a 7.81-fold (95% CI: 2.07- to 29.50-fold) increased risk of LV40 at follow-up. Conclusions In CCS, an initial surveillance EF, in addition to anthracyclines and chest-directed radiotherapy dose, improves the 10-year prediction for LVD40. Through this strategy, both the identification of low-risk survivors in whom the surveillance frequency may be reduced and a group of survivors at increased risk of LVD40 could be identified.
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16
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Ehrhardt MJ. Progress Toward Improving Recommended Screening Practices in Survivors of Childhood Cancer at Risk for Cardiomyopathy. JACC CardioOncol 2021; 3:73-75. [PMID: 34396307 PMCID: PMC8352024 DOI: 10.1016/j.jaccao.2020.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
- Matthew J. Ehrhardt
- Department of Oncology and Department of Epidemiology and Cancer Control, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
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17
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Diagnosis, Prevention, Treatment and Surveillance of Anthracycline-Induced Cardiovascular Toxicity in Pediatric Cancer Survivors. HEARTS 2021. [DOI: 10.3390/hearts2010005] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Advances in pediatric cancer therapies have dramatically improved the likelihood of survival. As survivors are aging, however, we are now understanding that treatment carries a significant risk of cardiovascular toxicity, which can develop immediately, or even many years after completing therapy. Anthracycline derivates are some of the most commonly used agents in pediatric oncology treatment protocols, which have a dose-dependent correlation with the development of cardiac toxicity. As we learn more about the mechanisms of toxicity, we are developing prevention strategies, including improvements in surveillance, to improve early diagnosis of heart disease. Current survivorship surveillance protocols often include screening echocardiograms to evaluate systolic function by measuring the ejection fraction or fractional shortening. However, these measurements alone are not enough to capture early myocardial changes. The use of additional imaging biomarkers, serum biomarkers, electrocardiograms, as well as cholesterol and blood pressure screening, are key to the early detection of cardiomyopathy and cardiovascular disease. Medical treatment strategies are the same as those used for heart failure from other causes, but earlier recognition and implementation can lead to improved long term outcomes.
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18
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Ehrhardt MJ, Ward ZJ, Liu Q, Chaudhry A, Nohria A, Border W, Fulbright JM, Mulrooney DA, Oeffinger KC, Nathan PC, Leisenring WM, Constine LS, Gibson TM, Chow EJ, Howell RM, Robison LL, Armstrong GT, Hudson MM, Diller L, Yasui Y, Armenian SH, Yeh JM. Cost-Effectiveness of the International Late Effects of Childhood Cancer Guideline Harmonization Group Screening Guidelines to Prevent Heart Failure in Survivors of Childhood Cancer. J Clin Oncol 2020; 38:3851-3862. [PMID: 32795226 PMCID: PMC7676889 DOI: 10.1200/jco.20.00418] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/09/2020] [Indexed: 02/06/2023] Open
Abstract
PURPOSE Survivors of childhood cancer treated with anthracyclines and/or chest-directed radiation are at increased risk for heart failure (HF). The International Late Effects of Childhood Cancer Guideline Harmonization Group (IGHG) recommends risk-based screening echocardiograms, but evidence supporting its frequency and cost-effectiveness is limited. PATIENTS AND METHODS Using the Childhood Cancer Survivor Study and St Jude Lifetime Cohort, we developed a microsimulation model of the clinical course of HF. We estimated long-term health outcomes and economic impact of screening according to IGHG-defined risk groups (low [doxorubicin-equivalent anthracycline dose of 1-99 mg/m2 and/or radiotherapy < 15 Gy], moderate [100 to < 250 mg/m2 or 15 to < 35 Gy], or high [≥ 250 mg/m2 or ≥ 35 Gy or both ≥ 100 mg/m2 and ≥ 15 Gy]). We compared 1-, 2-, 5-, and 10-year interval-based screening with no screening. Screening performance and treatment effectiveness were estimated based on published studies. Costs and quality-of-life weights were based on national averages and published reports. Outcomes included lifetime HF risk, quality-adjusted life-years (QALYs), lifetime costs, and incremental cost-effectiveness ratios (ICERs). Strategies with ICERs < $100,000 per QALY gained were considered cost-effective. RESULTS Among the IGHG risk groups, cumulative lifetime risks of HF without screening were 36.7% (high risk), 24.7% (moderate risk), and 16.9% (low risk). Routine screening reduced this risk by 4% to 11%, depending on frequency. Screening every 2, 5, and 10 years was cost-effective for high-risk survivors, and every 5 and 10 years for moderate-risk survivors. In contrast, ICERs were > $175,000 per QALY gained for all strategies for low-risk survivors, representing approximately 40% of those for whom screening is currently recommended. CONCLUSION Our findings suggest that refinement of recommended screening strategies for IGHG high- and low-risk survivors is needed, including careful reconsideration of discontinuing asymptomatic left ventricular dysfunction and HF screening in low-risk survivors.
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Affiliation(s)
- Matthew J. Ehrhardt
- Department of Oncology, St Jude Children’s Research Hospital, Memphis, TN
- Department of Epidemiology and Cancer Control, St Jude Children’s Research Hospital, Memphis, TN
| | - Zachary J. Ward
- Center for Health Decision Science, Harvard T.H. Chan School of Public Health, Boston, MA
| | - Qi Liu
- Department of Public Health Sciences, University of Alberta, Edmonton, Alberta, Canada
| | - Aeysha Chaudhry
- Division of General Pediatrics, Boston Children’s Hospital, Boston, MA
| | - Anju Nohria
- Department of Medicine, Brigham and Women’s Hospital, Boston, MA
| | - William Border
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA
| | - Joy M. Fulbright
- Department of Pediatrics, The Children’s Mercy Hospital, Kansas City, MO
| | - Daniel A. Mulrooney
- Department of Oncology, St Jude Children’s Research Hospital, Memphis, TN
- Department of Epidemiology and Cancer Control, St Jude Children’s Research Hospital, Memphis, TN
| | | | - Paul C. Nathan
- Department of Pediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Wendy M. Leisenring
- Clinical Statistics and Cancer Prevention Programs, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Louis S. Constine
- Departments of Radiation Oncology and Pediatrics, University of Rochester Medical Center, Rochester, NY
| | - Todd M. Gibson
- Department of Epidemiology and Cancer Control, St Jude Children’s Research Hospital, Memphis, TN
| | - Eric J. Chow
- Department of Pediatrics, Seattle Children’s Hospital, University of Washington, Seattle, WA
- Clinical Research and Public Health Sciences Divisions, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Rebecca M. Howell
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Leslie L. Robison
- Department of Epidemiology and Cancer Control, St Jude Children’s Research Hospital, Memphis, TN
| | - Gregory T. Armstrong
- Department of Epidemiology and Cancer Control, St Jude Children’s Research Hospital, Memphis, TN
| | - Melissa M. Hudson
- Department of Oncology, St Jude Children’s Research Hospital, Memphis, TN
- Department of Epidemiology and Cancer Control, St Jude Children’s Research Hospital, Memphis, TN
| | - Lisa Diller
- Dana-Farber/Boston Children’s Cancer and Blood Disorders Center, Boston, MA
| | - Yutaka Yasui
- Department of Epidemiology and Cancer Control, St Jude Children’s Research Hospital, Memphis, TN
| | - Saro H. Armenian
- Department of Population Sciences, City of Hope Medical Center, Duarte, CA
| | - Jennifer M. Yeh
- Division of General Pediatrics, Boston Children’s Hospital, Boston, MA
- Harvard Medical School, Boston, MA
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19
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Hodgson DC. Cardiac Screening for Childhood Cancer Survivors Can Be Improved With Existing Technology. J Clin Oncol 2020; 38:3827-3829. [PMID: 33026936 DOI: 10.1200/jco.20.02374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- David C Hodgson
- Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada.,Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, ON, Canada.,Pediatric Oncology Group of Ontario, Toronto, ON, Canada
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20
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Kunst N, Wang SY, Hood A, Mougalian SS, DiGiovanna MP, Adelson K, Pusztai L. Cost-Effectiveness of Neoadjuvant-Adjuvant Treatment Strategies for Women With ERBB2 (HER2)-Positive Breast Cancer. JAMA Netw Open 2020; 3:e2027074. [PMID: 33226431 PMCID: PMC7684449 DOI: 10.1001/jamanetworkopen.2020.27074] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
IMPORTANCE The neoadjuvant treatment options for ERBB2-positive (also known as HER2-positive) breast cancer are associated with different rates of pathologic complete response (pCR). The KATHERINE trial showed that adjuvant trastuzumab emtansine (T-DM1) can reduce recurrence in patients with residual disease compared with patients treated with trastuzumab; however, T-DM1 and other ERBB2-targeted agents are costly, and understanding the costs and health consequences of various combinations of neoadjuvant followed by adjuvant treatments in the United States is needed. OBJECTIVE To examine the costs and disease outcomes associated with selection of various neoadjuvant followed by adjuvant treatment strategies for patients with ERBB2-positive breast cancer. DESIGN, SETTING, AND PARTICIPANTS In this economic evaluation, a decision-analytic model was developed to evaluate various neoadjuvant followed by adjuvant treatment strategies for women with ERBB2-positive breast cancer from a health care payer perspective in the United States. The model was informed by the KATHERINE trial, other clinical trials with different regimens from the KATHERINE trial, the Flatiron Health Database, McKesson Corporation data, and other evidence in the published literature. Starting trial median age for KATHERINE patients was 49 years (range, 24-79 years in T-DM1 arm and 23-80 years in trastuzumab arm). The model simulated patients receiving 5 different neoadjuvant followed by adjuvant treatment strategies. Data analyses were performed from March 2019 to August 2020. EXPOSURE There were 4 neoadjuvant regimens: (1) HP: trastuzumab (H) plus pertuzumab (P), (2) THP: paclitaxel (T) plus H plus P, (3) DDAC-THP: dose-dense anthracycline/cyclophosphamide (DDAC) plus THP, (4) TCHP: docetaxel (T) plus carboplatin (C) plus HP. All patients with pCR, regardless of neoadjuvant regimen, received adjuvant H. Patients with residual disease received different adjuvant therapies depending on the neoadjuvant regimen according to the 5 following strategies: (1) neoadjuvant DDAC-THP followed by adjuvant H, (2) neoadjuvant DDAC-THP followed by adjuvant T-DM1, (3) neoadjuvant THP followed by adjuvant DDAC plus T-DM1, (4) neoadjuvant HP followed by adjuvant DDAC/THP plus T-DM1, or (5) neoadjuvant TCHP followed by adjuvant T-DM1. MAIN OUTCOMES AND MEASURES Lifetime costs in 2020 US dollars and quality-adjusted life-years (QALYs) were estimated for each treatment strategy, and incremental cost-effectiveness ratios were estimated. A strategy was classified as dominated if it was associated with fewer QALYs at higher costs than the alternative. RESULTS In the base-case analysis, costs ranged from $415 833 (strategy 3) to $518 859 (strategy 4), and QALYs ranged from 9.67 (strategy 1) to 10.73 (strategy 3). Strategy 3 was associated with the highest health benefits (10.73 QALYs) and lowest costs ($415 833) and dominated all other strategies. Probabilistic analysis confirmed that this strategy had the highest probability of cost-effectiveness (>70% at willingness-to-pay thresholds of $0-200,000/QALY) and was associated with the highest net benefit. CONCLUSIONS AND RELEVANCE These results suggest that neoadjuvant THP followed by adjuvant H for patients with pCR or followed by adjuvant DDAC plus T-DM1 for patients with residual disease was associated with the highest health benefits and lowest costs for women with ERBB2-positive breast cancer compared with other treatment strategies considered.
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MESH Headings
- Ado-Trastuzumab Emtansine/economics
- Ado-Trastuzumab Emtansine/therapeutic use
- Adult
- Aged
- Anthracyclines/economics
- Anthracyclines/therapeutic use
- Antibodies, Monoclonal, Humanized/economics
- Antibodies, Monoclonal, Humanized/therapeutic use
- Antineoplastic Agents, Immunological/economics
- Antineoplastic Agents, Immunological/therapeutic use
- Antineoplastic Agents, Phytogenic/economics
- Antineoplastic Agents, Phytogenic/therapeutic use
- Breast Neoplasms/genetics
- Breast Neoplasms/pathology
- Breast Neoplasms/therapy
- Case-Control Studies
- Cost-Benefit Analysis
- Cross-Linking Reagents/economics
- Cross-Linking Reagents/therapeutic use
- Drug Therapy, Combination
- Female
- Humans
- Immunosuppressive Agents/economics
- Immunosuppressive Agents/therapeutic use
- Middle Aged
- Neoadjuvant Therapy/economics
- Paclitaxel/economics
- Paclitaxel/therapeutic use
- Quality-Adjusted Life Years
- Receptor, ErbB-2/genetics
- Trastuzumab/economics
- Trastuzumab/therapeutic use
- Tubulin Modulators/economics
- Tubulin Modulators/therapeutic use
- United States/epidemiology
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Affiliation(s)
- Natalia Kunst
- Department of Health Management and Health Economics, University of Oslo, Oslo, Norway
- Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale School of Medicine, New Haven, Connecticut
- Public Health Modeling Unit, Yale University School of Public Health, New Haven, Connecticut
- Department of Epidemiology and Data Science, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Shi-Yi Wang
- Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale School of Medicine, New Haven, Connecticut
- Department of Chronic Disease Epidemiology, Yale University School of Public Health, New Haven, Connecticut
| | - Annette Hood
- Smilow Cancer Hospital, Yale New Haven Hospital, New Haven, Connecticut
| | - Sarah S. Mougalian
- Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale School of Medicine, New Haven, Connecticut
- Yale Cancer Center, Yale School of Medicine, New Haven, Connecticut
| | | | - Kerin Adelson
- Yale Cancer Center, Yale School of Medicine, New Haven, Connecticut
| | - Lajos Pusztai
- Yale Cancer Center, Yale School of Medicine, New Haven, Connecticut
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21
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Chen Y, Chow EJ, Oeffinger KC, Border WL, Leisenring WM, Meacham LR, Mulrooney DA, Sklar CA, Stovall M, Robison LL, Armstrong GT, Yasui Y. Traditional Cardiovascular Risk Factors and Individual Prediction of Cardiovascular Events in Childhood Cancer Survivors. J Natl Cancer Inst 2020; 112:256-265. [PMID: 31161223 DOI: 10.1093/jnci/djz108] [Citation(s) in RCA: 66] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Revised: 03/23/2019] [Accepted: 05/21/2019] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Childhood cancer survivors have an increased risk of heart failure, ischemic heart disease, and stroke. They may benefit from prediction models that account for cardiotoxic cancer treatment exposures combined with information on traditional cardiovascular risk factors such as hypertension, dyslipidemia, and diabetes. METHODS Childhood Cancer Survivor Study participants (n = 22 643) were followed through age 50 years for incident heart failure, ischemic heart disease, and stroke. Siblings (n = 5056) served as a comparator. Participants were assessed longitudinally for hypertension, dyslipidemia, and diabetes based on self-reported prescription medication use. Half the cohort was used for discovery; the remainder for replication. Models for each outcome were created for survivors ages 20, 25, 30, and 35 years at the time of prediction (n = 12 models). RESULTS For discovery, risk scores based on demographic, cancer treatment, hypertension, dyslipidemia, and diabetes information achieved areas under the receiver operating characteristic curve and concordance statistics 0.70 or greater in 9 and 10 of the 12 models, respectively. For replication, achieved areas under the receiver operating characteristic curve and concordance statistics 0.70 or greater were observed in 7 and 9 of the models, respectively. Across outcomes, the most influential exposures were anthracycline chemotherapy, radiotherapy, diabetes, and hypertension. Survivors were then assigned to statistically distinct risk groups corresponding to cumulative incidences at age 50 years of each target outcome of less than 3% (moderate-risk) or approximately 10% or greater (high-risk). Cumulative incidence of all outcomes was 1% or less among siblings. CONCLUSIONS Traditional cardiovascular risk factors remain important for predicting risk of cardiovascular disease among adult-age survivors of childhood cancer. These prediction models provide a framework on which to base future surveillance strategies and interventions.
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Affiliation(s)
- Yan Chen
- University of Alberta, Edmonton, Alberta, Canada
| | - Eric J Chow
- Fred Hutchinson Cancer Research Center, University of Washington, Seattle, WA
| | | | | | - Wendy M Leisenring
- Fred Hutchinson Cancer Research Center, University of Washington, Seattle, WA
| | | | | | | | - Marilyn Stovall
- The University of Texas, MD Anderson Cancer Center, Houston, TX
| | | | | | - Yutaka Yasui
- University of Alberta, Edmonton, Alberta, Canada.,St. Jude Children's Research Hospital, Memphis, TN
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22
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Keramida K, Farmakis D, López Fernández T, Lancellotti P. Focused echocardiography in cardio‐oncology. Echocardiography 2020; 37:1149-1158. [DOI: 10.1111/echo.14800] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 03/19/2020] [Accepted: 07/07/2020] [Indexed: 01/27/2023] Open
Affiliation(s)
- Kalliopi Keramida
- Cardio‐Oncology Clinic Heart Failure Unit Department of Cardiology Attikon University Hospital National and Kapodistrian University of Athens Medical School Athens Greece
- University of Cyprus Medical School Nicosia Cyprus
| | | | | | - Patrizio Lancellotti
- GIGA Cardiovascular Sciences Department of Cardiology and Radiology CHU Sart Tilman University of Liège Hospital Liège Belgium
- Gruppo Villa Maria Care and Research Lugo Italy
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23
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Bottinor WJ, Friedman DL, Ryan TD, Wang L, Yu C, Borinstein SC, Godown J. Cardiovascular disease and asymptomatic childhood cancer survivors: Current clinical practice. Cancer Med 2020; 9:5500-5508. [PMID: 32558321 PMCID: PMC7402829 DOI: 10.1002/cam4.3190] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Revised: 03/19/2020] [Accepted: 05/13/2020] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND It is poorly understood how cardiovascular screening in asymptomatic childhood cancer survivors (CCS) is applied to and impacts clinical care. OBJECTIVES To describe the current role of cardiovascular screening in the clinical care of asymptomatic CCS. METHODS At 50 pediatric academic medical centers, a childhood cancer survivorship clinic director, pediatric cardiologist, and adult cardiologist with a focus on CCS were identified and invited to participate in a survey. Surveys were managed electronically. Categorical data were analyzed using nonparametric methods. RESULTS Of the 95 (63%) respondents, 39% were survivorship practitioners, and 61% were cardiologists. Eighty-eight percent of survivorship practitioners reported that greater than half of CCS received cardiovascular screening. CCS followed by adult cardiology were more likely to be seen by a cardio-oncologist. Those followed by pediatric cardiology were more likely to be seen by a heart failure/transplant specialist. Common reasons for referral to cardiology were abnormal cardiovascular imaging or concerns a CCS was at high risk for cardiovascular disease. Ninety-two percent of cardiologists initiated angiotensin converting enzyme inhibitor or angiotensin receptor blocker therapy for mild systolic dysfunction. Adult cardiologists initiated beta-blocker therapy for less severe systolic dysfunction compared to pediatric cardiologists (P < .001). Pediatric cardiologists initiated mineralocorticoid therapy for less severe systolic dysfunction compared to adult cardiologists (P = .025). Practitioners (93%) support a multi-institutional collaboration to standardize cardiovascular care for CCS. CONCLUSIONS While there is much common ground in the clinical approach to CCS, heterogeneity is evident. This highlights the need for cohesive, multi-institutional, standardized approaches to cardiovascular management in CCS.
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Affiliation(s)
- Wendy J Bottinor
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Debra L Friedman
- Department of Pediatrics, Division of Hematology-Oncology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Thomas D Ryan
- Department of Pediatrics, University of Cincinnati College of Medicine; Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Li Wang
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Chang Yu
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Scott C Borinstein
- Department of Pediatrics, Division of Hematology-Oncology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Justin Godown
- Department of Pediatrics, Division of Pediatric Cardiology, Vanderbilt University Medical Center, Nashville, TN, USA
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24
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Armenian SH, Gibson CJ, Rockne RC, Ness KK. Premature Aging in Young Cancer Survivors. J Natl Cancer Inst 2020; 111:226-232. [PMID: 30715446 DOI: 10.1093/jnci/djy229] [Citation(s) in RCA: 51] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Revised: 11/29/2018] [Accepted: 12/10/2018] [Indexed: 12/23/2022] Open
Abstract
Advances in early detection, treatment, and supportive care have resulted in an estimated 16 million cancer survivors who are alive in the United States today. Outcomes have notably improved for children with cancer as well as young adults with hematologic malignancies due, in part, to the intensification of cancer treatment, including the use of hematopoietic cell transplantation. Emerging evidence suggests that these cancer survivors are at risk for premature aging, manifesting as early onset of chronic health conditions and a higher risk of mortality compared with the general population. Although the pathophysiology of premature aging in these survivors has not been fully elucidated, emerging concepts in aging research could help shed light on this phenomenon. Longitudinal studies are needed to better characterize aging in these survivors, setting the stage for much-needed interventions to halt the trajectory of accelerated aging. These efforts will be enhanced through collaborations between translational researchers, clinical oncologists, primary care providers, geriatricians, patient caretakers, and other stakeholders committed to improving the lives of the growing population of survivors.
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Affiliation(s)
| | | | | | - Kirsten K Ness
- Department of Epidemiology and Cancer Control, St Jude Children's Research Hospital, Memphis, TN
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25
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Dewilde S, Carroll K, Nivelle E, Sawyer J. Evaluation of the cost-effectiveness of dexrazoxane for the prevention of anthracycline-related cardiotoxicity in children with sarcoma and haematologic malignancies: a European perspective. COST EFFECTIVENESS AND RESOURCE ALLOCATION 2020; 18:7. [PMID: 32063753 PMCID: PMC7011276 DOI: 10.1186/s12962-020-0205-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Accepted: 02/04/2020] [Indexed: 12/18/2022] Open
Abstract
Background Anthracycline-treated childhood cancer survivors are at higher risk of cardiotoxicity, especially with cumulative doses received above 250 mg/m2. Dexrazoxane is the only option recommended for cardiotoxicity prevention in high-risk patients supported by randomised trials but its cost-effectiveness in paediatric cancer patients has not been established. Methods A cost-effectiveness model applicable to different national healthcare system perspectives, which simulates 10,000 patients with either sarcoma or haematologic malignancies, based upon baseline characteristics including gender, age at diagnosis, cumulative anthracycline dose and exposure to chest irradiation. Risk equations for developing congestive heart failure and death from recurrence of the original cancer, secondary malignant neoplasms, cardiac death, pulmonary death, and death from other causes were derived from published literature. These are applied to the individual simulated patients and time until development of these events was determined. The treatment effect of dexrazoxane on the risk of CHF or death was based upon a meta-analysis of randomised and non-randomised dexrazoxane studies in each tumour type. The model includes country specific data for drug and administration costs, all aspects of heart failure diagnosis and management, and death due to different causes for each of the five countries considered; France, Germany, the UK, Italy, and Spain. Results Dexrazoxane treatment resulted in a mean QALY benefit across the five countries ranging from 0.530 to 0.683 per dexrazoxane-treated patient. Dexrazoxane was cost-effective for paediatric patients receiving anthracycline treatment for sarcoma and for haematologic malignancies, irrespective of the cumulative anthracycline dose received. The Incremental Cost Effectiveness Ratio (ICER) was favourable in all countries irrespective of anthracycline dose for both sarcoma and haematological malignancies (range: dominant to €2196). Individual ICER varied considerably according to country with dominance demonstrated for dexrazoxane in Spain and Italy and ratios approximately double the European average in the UK and Germany. Conclusions Dexrazoxane is a highly cost-effective therapy for the prevention of anthracycline cardiotoxicity in paediatric patients with sarcoma or haematological malignancies in Europe, irrespective of the healthcare system in which they receive treatment. These benefits persist when patients who receive doses of anthracycline > 250 mg/m2 are included in the model.
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Affiliation(s)
| | | | | | - James Sawyer
- Prism Ideas Ltd, Morston House, Beam Heath Way, Nantwich, CW5 6GD UK
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26
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Curigliano G, Lenihan D, Fradley M, Ganatra S, Barac A, Blaes A, Herrmann J, Porter C, Lyon AR, Lancellotti P, Patel A, DeCara J, Mitchell J, Harrison E, Moslehi J, Witteles R, Calabro MG, Orecchia R, de Azambuja E, Zamorano JL, Krone R, Iakobishvili Z, Carver J, Armenian S, Ky B, Cardinale D, Cipolla CM, Dent S, Jordan K. Management of cardiac disease in cancer patients throughout oncological treatment: ESMO consensus recommendations. Ann Oncol 2020; 31:171-190. [PMID: 31959335 PMCID: PMC8019325 DOI: 10.1016/j.annonc.2019.10.023] [Citation(s) in RCA: 510] [Impact Index Per Article: 127.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Revised: 10/18/2019] [Accepted: 10/21/2019] [Indexed: 12/13/2022] Open
Abstract
Cancer and cardiovascular (CV) disease are the most prevalent diseases in the developed world. Evidence increasingly shows that these conditions are interlinked through common risk factors, coincident in an ageing population, and are connected biologically through some deleterious effects of anticancer treatment on CV health. Anticancer therapies can cause a wide spectrum of short- and long-term cardiotoxic effects. An explosion of novel cancer therapies has revolutionised this field and dramatically altered cancer prognosis. Nevertheless, these new therapies have introduced unexpected CV complications beyond heart failure. Common CV toxicities related to cancer therapy are defined, along with suggested strategies for prevention, detection and treatment. This ESMO consensus article proposes to define CV toxicities related to cancer or its therapies and provide guidance regarding prevention, screening, monitoring and treatment of CV toxicity. The majority of anticancer therapies are associated with some CV toxicity, ranging from asymptomatic and transient to more clinically significant and long-lasting cardiac events. It is critical however, that concerns about potential CV damage resulting from anticancer therapies should be weighed against the potential benefits of cancer therapy, including benefits in overall survival. CV disease in patients with cancer is complex and treatment needs to be individualised. The scope of cardio-oncology is wide and includes prevention, detection, monitoring and treatment of CV toxicity related to cancer therapy, and also ensuring the safe development of future novel cancer treatments that minimise the impact on CV health. It is anticipated that the management strategies discussed herein will be suitable for the majority of patients. Nonetheless, the clinical judgment of physicians remains extremely important; hence, when using these best clinical practices to inform treatment options and decisions, practitioners should also consider the individual circumstances of their patients on a case-by-case basis.
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Affiliation(s)
- G. Curigliano
- European Institute of Oncology IRCCS, Milan
- Department of Oncology and Haematology (DIPO), University of Milan, Milan, Italy
| | - D. Lenihan
- Cardiovascular Division, Cardio-Oncology Center of Excellence, Washington University Medical Center, St. Louis
| | - M. Fradley
- Cardio-oncology Program, Division of Cardiovascular Medicine, Morsani College of Medicine and H. Lee Moffitt Cancer Center and Research Institute, University of South Florida, Tampa
| | - S. Ganatra
- Cardio-Oncology Program, Lahey Medical Center, Burlington
| | - A. Barac
- Cardio-Oncology Program, Medstar Heart and Vascular Institute and MedStar Georgetown Cancer Institute, Georgetown University Hospital, Washington DC
| | - A. Blaes
- Division of Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis
| | | | - C. Porter
- University of Kansas Medical Center, Lawrence, USA
| | - A. R. Lyon
- Royal Brompton Hospital and Imperial College, London, UK
| | - P. Lancellotti
- GIGA Cardiovascular Sciences, Acute Care Unit, Heart Failure Clinic, CHU Sart Tilman, University Hospital of Liège, Liège, Belgium
| | - A. Patel
- Morsani College of Medicine, University of South Florida, Tampa
| | - J. DeCara
- Medicine Section of Cardiology, University of Chicago, Chicago
| | - J. Mitchell
- Washington University Medical Center, St. Louis
| | - E. Harrison
- HCA Memorial Hospital and University of South Florida, Tampa
| | - J. Moslehi
- Vanderbilt University School of Medicine, Nashville
| | - R. Witteles
- Division of Cardiovascular Medicine, Falk CVRC, Stanford University School of Medicine, Stanford, USA
| | - M. G. Calabro
- Department of Anesthesia and Intensive Care, IRCCS, San Raffaele Scientific Institute, Milan, Italy
| | | | - E. de Azambuja
- Institut Jules Bordet and L’Université Libre de Bruxelles, Brussels, Belgium
| | | | - R. Krone
- Division of Cardiology, Washington University, St. Louis, USA
| | - Z. Iakobishvili
- Clalit Health Services, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - J. Carver
- Division of Cardiology, Abramson Cancer Center, Hospital of the University of Pennsylvania, Philadelphia
| | - S. Armenian
- Department of Population Sciences, City of Hope Comprehensive Cancer Center, Duarte
| | - B. Ky
- University of Pennsylvania School of Medicine, Philadelphia, USA
| | - D. Cardinale
- Cardioncology Unit, European Institute of Oncology, IRCCS, Milan
| | - C. M. Cipolla
- Cardiology Department, European Institute of Oncology, IRCCS, Milan, Italy
| | - S. Dent
- Duke Cancer Institute, Duke University, Durham, USA
| | - K. Jordan
- Department of Medicine V, Hematology, Oncology and Rheumatology, University of Heidelberg, Heidelberg, Germany
| | - ESMO Guidelines Committee
- Correspondence to: ESMO Guidelines Committee, ESMO Head Office, Via Ginevra 4, CH-6900 Lugano, Switzerland, (ESMO Guidelines Committee)
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27
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Wolf CM, Reiner B, Kühn A, Hager A, Müller J, Meierhofer C, Oberhoffer R, Ewert P, Schmid I, Weil J. Subclinical Cardiac Dysfunction in Childhood Cancer Survivors on 10-Years Follow-Up Correlates With Cumulative Anthracycline Dose and Is Best Detected by Cardiopulmonary Exercise Testing, Circulating Serum Biomarker, Speckle Tracking Echocardiography, and Tissue Doppler Imaging. Front Pediatr 2020; 8:123. [PMID: 32296665 PMCID: PMC7136405 DOI: 10.3389/fped.2020.00123] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Accepted: 03/06/2020] [Indexed: 12/13/2022] Open
Abstract
Background: Survivors of childhood cancer are at risk for anthracycline- and/or radiotherapy-induced cardiotoxicity. Aims: The aim of this study was to assess clinical, laboratory, and imaging parameters of subclinical cardiovascular disease in childhood cancer survivors. Methods: Patients underwent cardiopulmonary exercise test (CPET), laboratory testing, transthoracic echocardiography (TTE) with tissue doppler imaging (TDI) and speckle tracking. A subset of patients also underwent cardiovascular magnetic resonance imaging (CMR). Findings were correlated to cumulative anthracycline and exposure to mediastinal irradiation during cancer treatment. In a subgroup analysis, TTE and CMR findings were compared to data from 40 gender- and age-matched patients with childhood onset hypertrophic cardiomyopathy (HCM). Results: Cardiac evaluation was performed in 79 patients (43 males) at 11.2 ± 4.5 years after cancer treatment. Oncologic diagnosis at a median age of 12.0 years was Hodgkin lymphoma in 20, sarcoma in 17, acute leukemia in 24, relapse leukemia in 10, and others in 8 patients. Cumulative anthracycline dose exceeded 300 mg/m2 in 28 patients. Twenty six patients also received mediastinal irradiation. Decreased peak respiratory oxygen uptake in % predicted on CPET, increased levels of N-terminal pro-brain natriuretic peptide (NTproBNP), increased global longitudinal strain on TTE speckle tracking, and diastolic dysfunction on TDI were the most prominent findings on detailed cardiology follow-up. In contrast to HCM patients, childhood cancer survivors did not show left ventricular hypertrophy (LVPWd z-score median 0.9 vs. 2.8, p < 0.001), hyperdynamic systolic function on TTE (Ejection fraction 62 ± 7 vs. 72 ± 12%, p = 0.001), or fibrotic myocardial changes on CMR (Late gadolinium positive 0/13 vs. 13/36, p = 0.001; extracellular volume fraction 22 ± 2 vs. 28 ± 3, p < 0.001) at time of follow-up. There was no correlation between chest radiation exposure and abnormal cardiac findings. Cumulative anthracycline dose was the only significant independent predictor on multivariate analysis for any cardiovascular abnormality on follow-up (p = 0.036). Conclusion: Increasing cumulative anthracycline dose during cancer treatment correlates with subclinical cardiac dysfunction in childhood cancer survivors best detected by elevated cardiac serum biomarkers, decreased exercise capacity on CPET, and abnormalities on echocardiographic speckle tracking and TDI.
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Affiliation(s)
- Cordula Maria Wolf
- Department of Congenital Heart Disease and Pediatric Cardiology, German Heart Center Munich, Technical University Munich, Munich, Germany
| | - Barbara Reiner
- Department of Congenital Heart Disease and Pediatric Cardiology, German Heart Center Munich, Technical University Munich, Munich, Germany.,Faculty of Sport and Health Sciences, Institute of Preventive Pediatrics, Technical University Munich, Munich, Germany
| | - Andreas Kühn
- Department of Congenital Heart Disease and Pediatric Cardiology, German Heart Center Munich, Technical University Munich, Munich, Germany
| | - Alfred Hager
- Department of Congenital Heart Disease and Pediatric Cardiology, German Heart Center Munich, Technical University Munich, Munich, Germany
| | - Jan Müller
- Department of Congenital Heart Disease and Pediatric Cardiology, German Heart Center Munich, Technical University Munich, Munich, Germany.,Faculty of Sport and Health Sciences, Institute of Preventive Pediatrics, Technical University Munich, Munich, Germany
| | - Christian Meierhofer
- Department of Congenital Heart Disease and Pediatric Cardiology, German Heart Center Munich, Technical University Munich, Munich, Germany
| | - Renate Oberhoffer
- Department of Congenital Heart Disease and Pediatric Cardiology, German Heart Center Munich, Technical University Munich, Munich, Germany.,Faculty of Sport and Health Sciences, Institute of Preventive Pediatrics, Technical University Munich, Munich, Germany
| | - Peter Ewert
- Department of Congenital Heart Disease and Pediatric Cardiology, German Heart Center Munich, Technical University Munich, Munich, Germany
| | - Irene Schmid
- Department of Pediatric Hematology and Oncology, Dr. von Hauner Children's Hospital, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Jochen Weil
- Department of Congenital Heart Disease and Pediatric Cardiology, German Heart Center Munich, Technical University Munich, Munich, Germany
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Armenian SH, Jurczak W, Carver JR, Gennari A, Minotti G, Ewer MS. Helping the cardio-oncologist: from real life to guidelines. Semin Oncol 2019; 46:433-436. [DOI: 10.1053/j.seminoncol.2019.01.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Accepted: 01/09/2019] [Indexed: 01/03/2023]
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Kenney LB, Ames B, Margossian R, Moss K, Michaud AL, Williams DN, Nohria A. Regional practice norms for the care of childhood cancer survivors at risk for cardiomyopathy: A Delphi study. Pediatr Blood Cancer 2019; 66:e27868. [PMID: 31148382 DOI: 10.1002/pbc.27868] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Revised: 05/13/2019] [Accepted: 05/17/2019] [Indexed: 11/05/2022]
Abstract
BACKGROUND Treatment-associated cardiomyopathy is a leading cause of morbidity and mortality for childhood cancer survivors (CCS). As evidence is not available to guide the management of CCS at risk for cardiomyopathy, we aim to describe the collective opinion of regional experts for the care of these patients using a consensus-based Delphi methodology. PROCEDURE Nineteen physicians from the New England region who care for CCS treated with cardiotoxic therapy (anthracyclines, thoracic radiation) participated in a Delphi panel querying their management approach, using three rounds of anonymous questionnaires formatted as five clinical scenarios. Consensus ≥ 89% agreement. RESULTS The response rate was 100% for the first round and 95% for subsequent rounds. Panelists reached consensus on screening asymptomatic CCS with serial echocardiograms (94%) and electrocardiograms (89%), with some disagreement on frequency during pregnancy (83%). All panelists agreed with exercise promotion, with no restrictions on weight training. Consensus was reached on indications for referrals; cardiology for asymptomatic left ventricular dysfunction (ALVD) (100%) and maternal-fetal medicine for pregnancy (94%). In the scenario of ALVD, there was disagreement on the benefit of additional cardiac testing (50% cardiologists recommended cardiac MRI), and although all panelists endorsed treating with angiotension-converting enzyme (ACE) inhibitors, most adult cardiologists (75%) also recommended therapy with beta blockers, compared with none of the pediatric cardiologists or primary-care physicians. CONCLUSIONS Despite a lack of evidence to guide the management of CCS at risk for cardiomyopathy, a panel of regional physicians reached consensus on managing most clinical scenarios. A controversial area requiring further study is the medical management of ALVD.
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Affiliation(s)
- Lisa B Kenney
- Dana-Farber Boston Children's Cancer and Blood Disorders Center, Harvard Medical School, Boston, Massachusetts
| | - Bethany Ames
- Department of Pediatrics, Children's Hospital at Dartmouth, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
| | - Renee Margossian
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Kerry Moss
- Department of Pediatric Hematology-Oncology, Connecticut Children's Medical Center, University of Connecticut Medical School, Hartford, Connecticut
| | | | - David N Williams
- Institutional Centers for Clinical and Translational Research, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Anju Nohria
- Cardiovascular Division, Brigham Women's Hospital, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts
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Zabih V, Kahane A, O'Neill NE, Ivers N, Nathan PC. Interventions to improve adherence to surveillance guidelines in survivors of childhood cancer: a systematic review. J Cancer Surviv 2019; 13:713-729. [PMID: 31338733 DOI: 10.1007/s11764-019-00790-w] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Accepted: 07/11/2019] [Indexed: 02/07/2023]
Abstract
PURPOSE Many survivors of childhood cancer are at high risk of late effects of their cancer therapy, including cardiac toxicity and subsequent malignant neoplasms (SMN). Current North American guidelines recommend periodic surveillance for these late effects. We conducted a systematic review of the literature to estimate rates of adherence to recommended surveillance and summarize studies evaluating interventions intended to increase adherence. METHODS We searched MEDLINE, Embase, Web of Science, and the Cumulative Index of Nursing and Allied Health Literature (CINAHL) for articles published between January 2000 and September 2018 that reported adherence to surveillance for cardiac toxicity and SMN (breast and colorectal cancer) and interventions implemented to improve completion of recommended testing. Risk of bias was assessed using relevant Cochrane checklists. Due to heterogeneity and overlapping study populations, we used narrative synthesis to summarize the findings. This review was registered in PROSPERO: CRD42018098878. RESULTS Thirteen studies met our inclusion criteria for assessing adherence to surveillance, while five assessed interventions to improve rates of surveillance. No studies met criteria for low risk of bias. Completion of recommended surveillance was lowest for colorectal cancer screening (11.5-30.0%) followed by cardiomyopathy (22.3-48.1%) and breast cancer (37.0-56.5%). Factors such as patient-provider communication, engagement with the health care system, and receipt of information were consistently reported to be associated with higher rates of surveillance. Of five randomized controlled trials aimed at improving surveillance, only two significantly increase completion of recommended testing-one for echocardiography and one for mammography. Both involved telephone outreach to encourage and facilitate these tests. CONCLUSION The majority of childhood cancer survivors at high risk of cardiac toxicity or SMN do not receive evidence-based surveillance. There is paucity of rigorous studies evaluating interventions to increase surveillance in this population. IMPLICATIONS FOR CANCER SURVIVORS Robust trials are needed to assess whether tailored interventions, designed based on unique characteristics and needs of each survivor population, could improve adherence.
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Affiliation(s)
- Veda Zabih
- Division of Hematology/Oncology, The Hospital for Sick Children, 555 University Avenue, Toronto, ON, M5G 1X8, Canada
| | | | | | - Noah Ivers
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
- Institute of Health Policy Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Paul C Nathan
- Division of Hematology/Oncology, The Hospital for Sick Children, 555 University Avenue, Toronto, ON, M5G 1X8, Canada.
- Institute of Health Policy Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.
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McDonald JP, MacNamara JP, Zaha VG. Challenges in Implementing Optimal Echocardiographic Screening in Cardio-Oncology. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2019; 21:39. [DOI: 10.1007/s11936-019-0740-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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Abu-Khalaf MM, Safonov A, Stratton J, Wang S, Hatzis C, Park E, Pusztai L, Gross CP, Russell R. Examining the cost-effectiveness of baseline left ventricular function assessment among breast cancer patients undergoing anthracycline-based therapy. Breast Cancer Res Treat 2019; 176:261-270. [PMID: 31020471 DOI: 10.1007/s10549-019-05178-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Accepted: 02/19/2019] [Indexed: 11/26/2022]
Abstract
BACKGROUND There is a lack of consensus to guide which breast cancer patients require left ventricular function assessment (LVEF) prior to anthracycline therapy; the cost-effectiveness of screening this patient population has not been previously evaluated. METHODS We performed a retrospective analysis of the Yale Nuclear Cardiology Database, including 702 patients with baseline equilibrium radionuclide angiography (ERNA) scan prior to anthracycline and/or trastuzumab therapy. We sought to examine associations between abnormal baseline LVEF and potential cardiac risk factors. Additionally, we designed a Markov model to determine the incremental cost-effectiveness ratio (ICER) of ERNA screening for women aged 55 with stage I-III breast cancer from a payer perspective over a lifetime horizon. RESULTS An abnormal LVEF was observed in 2% (n = 14) of patients. There were no significant associations on multivariate analysis performed on self-reported risk factors. Our analysis showed LVEF screening is cost-effective with ICER of $45,473 per QALY gained. For a willingness-to-pay threshold of $100,000/ QALY, LVEF screening had an 81.9% probability of being cost-effective. Under the same threshold, screening was cost-effective for non-anthracycline cardiotoxicity risk of RR ≤ 0.58, as compared to anthracycline regimens. CONCLUSIONS Age, preexisting cardiac risk factors and coronary artery disease did not predict a baseline abnormal LVEF. While the prevalence of an abnormal baseline LVEF is low in patients with breast cancer, our results suggest that cardiac screening prior to anthracycline is cost-effective.
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Affiliation(s)
- Maysa M Abu-Khalaf
- Section of Solid Tumors, Sidney Kimmel Cancer Center, Thomas Jefferson University, 1025 Walnut Street, 7th Floor, Philadelphia, PA, 19107, USA.
| | - Anton Safonov
- Hospital of University of Pennsylvania, Philadelphia, PA, USA
| | | | - Shiyi Wang
- Yale University School of Public Health, New Haven, CT, USA
- Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale University School of Medicine, New Haven, CT, USA
| | - Christos Hatzis
- Section of Medical Oncology, Yale University School of Medicine, New Haven, CT, USA
| | - Esther Park
- Diagnostic Radiology Department, UCLA, Los Angeles, CA, USA
| | - Lajos Pusztai
- Section of Medical Oncology, Yale University School of Medicine, New Haven, CT, USA
| | - Cary P Gross
- Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale University School of Medicine, New Haven, CT, USA
| | - Raymond Russell
- Cardiovascular Institute of Rhode Island, Warren Alpert Medical School of Brown University, Providence, RI, USA
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Chow EJ, Leger KJ, Bhatt NS, Mulrooney DA, Ross CJ, Aggarwal S, Bansal N, Ehrhardt MJ, Armenian SH, Scott JM, Hong B. Paediatric cardio-oncology: epidemiology, screening, prevention, and treatment. Cardiovasc Res 2019; 115:922-934. [PMID: 30768157 PMCID: PMC6452306 DOI: 10.1093/cvr/cvz031] [Citation(s) in RCA: 63] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2018] [Revised: 01/18/2019] [Accepted: 02/13/2019] [Indexed: 12/11/2022] Open
Abstract
With 5-year survival of children with cancer exceeding 80% in developed countries, premature cardiovascular disease is now a major cause of early morbidity and mortality. In addition to the acute and chronic cardiotoxic effects of anthracyclines, related chemotherapeutics, and radiation, a growing number of new molecular targeted agents may also have detrimental effects on the cardiovascular system. Survivors of childhood cancer also may have earlier development of conventional cardiovascular risk factors such as hypertension, dyslipidaemia, and diabetes, which further increase their risk of serious cardiovascular disease. This review will examine the epidemiology of acute and chronic cardiotoxicity relevant to paediatric cancer patients, including genetic risk factors. We will also provide an overview of current screening recommendations, including the evidence regarding both imaging (e.g. echocardiography and magnetic resonance imaging) and blood-based biomarkers. Various primary and secondary prevention strategies will also be discussed, primarily in relation to anthracycline-related cardiomyopathy. Finally, we review the available evidence related to the management of systolic and diastolic dysfunction in paediatric cancer patients and childhood cancer survivors.
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Affiliation(s)
- Eric J Chow
- Department of Pediatrics, Seattle Children’s Hospital, University of Washington, Seattle, WA, USA
- Clinical Research and Public Health Sciences Divisions, Fred Hutchinson Cancer Research Center, 1100 Fairview Ave N., PO Box 19024, Mailstop M4-C308, Seattle, WA 98109, USA
| | - Kasey J Leger
- Department of Pediatrics, Seattle Children’s Hospital, University of Washington, Seattle, WA, USA
| | - Neel S Bhatt
- Department of Oncology, St. Jude Children’s Research Hospital, Memphis, TN, USA
| | - Daniel A Mulrooney
- Department of Oncology, St. Jude Children’s Research Hospital, Memphis, TN, USA
| | - Colin J Ross
- Faculty of Pharmaceutical Sciences, University of British Columbia, BC Children’s Hospital, Vancouver, BC, Canada
| | - Sanjeev Aggarwal
- Division of Pediatric Cardiology, Children’s Hospital of Michigan, Wayne State University, Detroit, MI, USA
| | - Neha Bansal
- Division of Pediatric Cardiology, Children’s Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Matthew J Ehrhardt
- Department of Oncology, St. Jude Children’s Research Hospital, Memphis, TN, USA
| | - Saro H Armenian
- Department of Population Sciences, City of Hope Medical Center, Duarte, CA, USA
| | - Jessica M Scott
- Exercise Oncology Research Laboratory, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Borah Hong
- Department of Pediatrics, Seattle Children’s Hospital, University of Washington, Seattle, WA, USA
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Treatment exposures stratify need for echocardiographic screening in asymptomatic long-term survivors of hematopoietic stem cell transplantation. Cardiol Young 2019; 29:338-343. [PMID: 30744727 DOI: 10.1017/s104795111800238x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
We sought to define the prevalence of echocardiographic abnormalities in long-term survivors of paediatric hematopoietic stem cell transplantation and determine the utility of screening in asymptomatic patients. We analysed echocardiograms performed on survivors who underwent hematopoietic stem cell transplantation from 1982 to 2006. A total of 389 patients were alive in 2017, with 114 having an echocardiogram obtained ⩾5 years post-infusion. A total of 95 patients had echocardiogram performed for routine surveillance. The mean time post-hematopoietic stem cell transplantation was 13 years. Of 95 patients, 77 (82.1%) had ejection fraction measured, and 10/77 (13.0%) had ejection fraction z-scores ⩽-2.0, which is abnormally low. Those patients with abnormal ejection fraction were significantly more likely to have been exposed to anthracyclines or total body irradiation. Among individuals who received neither anthracyclines nor total body irradiation, only 1/31 (3.2%) was found to have an abnormal ejection fraction of 51.4%, z-score -2.73. In the cohort of 77 patients, the negative predictive value of having a normal ejection fraction given no exposure to total body irradiation or anthracyclines was 96.7% at 95% confidence interval (83.3-99.8%). Systolic dysfunction is relatively common in long-term survivors of paediatric hematopoietic stem cell transplantation who have received anthracyclines or total body irradiation. Survivors who are asymptomatic and did not receive radiation or anthracyclines likely do not require surveillance echocardiograms, unless otherwise indicated.
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SEOM clinical guidelines on cardiovascular toxicity (2018). Clin Transl Oncol 2019; 21:94-105. [PMID: 30627982 PMCID: PMC6339681 DOI: 10.1007/s12094-018-02017-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Accepted: 12/12/2018] [Indexed: 12/21/2022]
Abstract
One of the most common side effects of cancer treatment is cardiovascular disease, which substantially impacts long-term survivor’s prognosis. Cardiotoxicity can be related with either a direct side effect of antitumor therapies or an accelerated development of cardiovascular diseases in the presence of preexisting risk factors. Even though it is widely recognized as an alarming clinical problem, scientific evidence is scarce in the management of these complications in cancer patients. Consequently, current recommendations are based on expert consensus. This Guideline represents SEOM’s ongoing commitment to progressing and improving supportive care for cancer patients.
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Fernandes RRA, Vianna CMDM, Freitas PGD, Guerra RL, Corrêa FM. Avaliação econômica do uso de dexrazoxano na profilaxia de cardiotoxicidade em crianças em tratamento quimioterápico com antraciclinas. CAD SAUDE PUBLICA 2019; 35:e00191518. [DOI: 10.1590/0102-311x00191518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Accepted: 03/22/2019] [Indexed: 11/22/2022] Open
Abstract
Resumo: O câncer em indivíduos de 0 a 19 anos é considerado raro, quando comparado à incidência em faixas etárias maiores, sendo estimado entre 2% e 3% de todos os tumores malignos registrados no Brasil. O uso de antraciclinas está frequentemente associado ao aparecimento de cardiotoxicidade e faz parte de aproximadamente 60% dos protocolos terapêuticos em oncologia pediátrica. Dentre as estratégias existentes para a prevenção de cardiotoxicidade, o dexrazoxano obteve resultados favoráveis pautados em desfechos intermediários (marcadores bioquímicos e medidas ecocardiográficas). Foi desenvolvida, neste trabalho, uma avaliação de custo-efetividade que compare o uso do dexrazoxano em diferentes populações, além de uma avaliação do impacto orçamentário causado pela possível incorporação da tecnologia. Foi utilizado o horizonte temporal de toda a vida do paciente e a perspectiva de análise do Sistema Único de Saúde. Uma análise de impacto orçamentário para cada tecnologia também foi construída. Após uma busca na literatura, foi desenvolvido um modelo de Markov capaz de comparar o uso do dexrazoxano em seis perfis de pacientes com risco de desenvolver cardiotoxicidade. Usar o medicamento nas crianças menores de cinco anos de idade se mostrou a alternativa mais custo-efetiva (razão de custo-efetividade incremental - RCEI de R$ 6.156,96), seguida de usar em todos os pacientes (RCEI de R$ 58.968,70). Caso o preço diminua a um valor menor que R$ 250,00 por frasco, a alternativa de usar em todas as crianças se torna a mais custo-efetiva. O impacto orçamentário ao final de cinco anos foi de R$ 30.622.404,81 para uso apenas nas crianças menores de cinco anos. Usar a tecnologia em todas as crianças produziria um impacto incremental de R$ 94.352.898,77.
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Armenian S, Bhatia S. Predicting and Preventing Anthracycline-Related Cardiotoxicity. Am Soc Clin Oncol Educ Book 2018; 38:3-12. [PMID: 30231396 DOI: 10.1200/edbk_100015] [Citation(s) in RCA: 81] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Anthracyclines (doxorubicin, daunorubicin, epirubicin, and idarubicin) are among the most potent chemotherapeutic agents and have truly revolutionized the management of childhood cancer. They form the backbone of chemotherapy regimens used to treat childhood acute lymphoblastic leukemia, acute myeloid leukemia, Hodgkin lymphoma, Ewing sarcoma, osteosarcoma, and neuroblastoma. More than 50% of children with cancer are treated with anthracyclines. The clinical utility of anthracyclines is compromised by dose-dependent cardiotoxicity, manifesting initially as asymptomatic cardiac dysfunction and evolving irreversibly to congestive heart failure. Childhood cancer survivors are at a five- to 15-fold increased risk for congestive heart failure compared with the general population. Once diagnosed with congestive heart failure, the 5-year survival rate is less than 50%. Prediction models have been developed for childhood cancer survivors (i.e., after exposure to anthracyclines) to identify those at increased risk for cardiotoxicity. Studies are currently under way to test risk-reducing strategies. There remains a critical need to identify patients with childhood cancer at diagnosis (i.e., prior to anthracycline exposure) such that noncardiotoxic therapies can be contemplated.
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Affiliation(s)
- Saro Armenian
- From the City of Hope, Duarte, CA; University of Alabama at Birmingham, Birmingham, AL
| | - Smita Bhatia
- From the City of Hope, Duarte, CA; University of Alabama at Birmingham, Birmingham, AL
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Two-Dimensional Speckle Tracking Echocardiography-Derived Strain Measurements in Survivors of Childhood Cancer on Angiotensin Converting Enzyme Inhibition or Receptor Blockade. Pediatr Cardiol 2018; 39:1404-1412. [PMID: 29789916 DOI: 10.1007/s00246-018-1910-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Accepted: 05/10/2018] [Indexed: 02/01/2023]
Abstract
Speckle tracking echocardiography (STE)-derived strain indices are believed to detect early cardiac dysfunction in survivors of childhood cancer and have potential to identify patients who may benefit from early heart failure treatment. However, effects of heart failure treatment on STE-derived strain measurements in this population are unknown. The aim of this study was to assess STE-derived strain measurements in survivors of childhood cancer treated with angiotensin converting enzyme inhibition or receptor blockade (ACEi/ARB). Two-dimensional speckle tracking analysis was retrospectively performed on echocardiograms from childhood cancer survivors before and during therapy with ACEi/ARB. Global left ventricular longitudinal and circumferential strain (GLS and GCS) and strain rates (LSR and CSR) were assessed and correlated with conventional echocardiographic measures of function. In 22 childhood cancer survivors (median age: 14.8, range 6.4-21.6 years), mean GLS (- 13.83 ± 0.74% to - 15.94 ± 0.74%, p = 0.002), GCS (- 18.79 ± 1.21% to - 20.74 ± 0.84%, p = 0.027), LSR (- 0.78 ± 0.04 to - 0.88 ± 0.04 s-1, p = 0.022), and CSR (- 1.08 ± 0.07 to - 1.21 ± 0.06 s-1, p = 0.027) improved on therapy. Improvement in GLS was maintained for greater than 1 year on ACEi/ARB (p = 0.02). Measures of strain and strain rate correlated with standard echocardiographic measures of function and were reproducible. These findings support the use of ACEi/ARB to treat post-chemotherapy-related cardiovascular changes in childhood cancer survivors, provide proof-of-concept that STE-derived strain and strain rate may be used to reliably monitor cardiac function during therapy, and support continued investigation into the clinical benefit of strain measurements in this population.
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Kwiecinska K, Strojny W, Pietrys D, Bik-Multanowski M, Siedlar M, Balwierz W, Skoczen S. Late effects in survivors of childhood acute lymphoblastic leukemia in the context of selected gene polymorphisms. Ital J Pediatr 2018; 44:92. [PMID: 30111348 PMCID: PMC6094582 DOI: 10.1186/s13052-018-0526-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Accepted: 07/17/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND It has been shown that approximately half of survivors of childhood acute lymphoblastic leukemia (ALL) have symptomatic late effects (LE) that may be severe or life-threatening. The aim of our study was to assess the health status of childhood ALL survivors after over 10 years of follow-up and to assess its relationships with gene polymorphisms, numbers and types of LEs, as well as with intensity of chemotherapy and cranial radiotherapy (CRT). METHODS We conducted a telephone survey in 125 ALL survivors (median time from completion of treatment was 12 years) and compared the results with those obtained in our previous study. Most of the patients were followed-up by local providers. RESULTS The prevalence of LEs of approximately 50% was similar in both study groups. More than one LE was found in almost 25% of patients. Endocrine LEs were less frequent than in our previous study (44% vs 22%), probably due to underdiagnosis. The prevalence of hepatitis B/C decreased from 30%/50 to 18% (counted together), and prevalence of neurologic LEs decreased from 18 to 6%. The increase in the rate of second malignancies was not significant (2% vs. 3%). Sixty four percent of patients continued their education at the time of the study. Approximately 51% of ALL survivors who have completed their education by the time of the study had no permanent employment, including 4 mothers of infants and 3 persons qualified for a disability living allowance. These employment problems may have been due to cognitive impairment. The offspring of the ALL survivors included 11 children, all of them healthy. Further analysis showed higher prevalence of hepatitis in patients treated with CRT (p = 0.0001). Genetic studies revealed higher prevalence of hepatitis in patients homozygous for the rs9939609A variant of the FTO gene compared with other patients (p = 0.03). Moreover, wild-type rs1137101 polymorphism (Q223R) of the and leptin receptor gene was more frequent in patients with psychological LEs (p = 0.03). CONCLUSIONS The prevalence of LEs in ALL survivors is of key importance. The transition of childhood ALL survivors from pediatric to adult care should be urgently improved to maintain continued follow-up provide high-quality care. TRIAL REGISTRATION Bioethics Committee of the Jagiellonian University approved the study protocol. Registration number: KBET/113/B/2006.
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Affiliation(s)
- Kinga Kwiecinska
- Department of Oncology and Hematology, Institute of Pediatrics, Jagiellonian University Medical College, Wielicka 265, 30-663, Krakow, Poland.
| | - Wojciech Strojny
- Department of Oncology and Hematology, Institute of Pediatrics, Jagiellonian University Medical College, Wielicka 265, 30-663, Krakow, Poland
| | - Danuta Pietrys
- Department of Oncology and Hematology, Institute of Pediatrics, Jagiellonian University Medical College, Wielicka 265, 30-663, Krakow, Poland
| | - Miroslaw Bik-Multanowski
- Department of Medical Genetics, Institute of Pediatrics, Jagiellonian University Medical College, Krakow, Poland
| | - Maciej Siedlar
- Department of Clinical Immunology, Chair of Clinical Immunology and Transplantation, Institute of Pediatrics, Jagiellonian University Medical College, Krakow, Poland
| | - Walentyna Balwierz
- Department of Oncology and Hematology, Institute of Pediatrics, Jagiellonian University Medical College, Wielicka 265, 30-663, Krakow, Poland
| | - Szymon Skoczen
- Department of Oncology and Hematology, Institute of Pediatrics, Jagiellonian University Medical College, Wielicka 265, 30-663, Krakow, Poland
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Nathan PC, Henderson TO, Kirchhoff AC, Park ER, Yabroff KR. Financial Hardship and the Economic Effect of Childhood Cancer Survivorship. J Clin Oncol 2018; 36:2198-2205. [DOI: 10.1200/jco.2017.76.4431] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
In addition to the long-term physical and psychological sequelae of cancer therapy, adult survivors of childhood cancer are at an elevated risk for financial hardship. Financial hardship can have material, psychological, and behavioral effects, including high out-of-pocket medical costs, asset depletion and debt, limitations in or inability to work, job lock, elevated stress and worry, and a delaying or forgoing of medical care because of cost. Most financial hardship research has been conducted in survivors of adult cancers. The few studies focused on childhood cancer survivors have shown that these individuals are at elevated risk for having difficulties with affording needed health care and report high out-of-pocket medical expenses, difficulty with paying medical bills, or consideration of filing for bankruptcy. Childhood cancer survivors are more likely to be unable to work or to have missed work because of poor health. They are more likely to report difficulties with obtaining insurance coverage and rely more frequently on government-sponsored insurance. Globally, countries able to provide curative cancer therapies have witnessed a growing population of survivors, which places a burden on their health care systems because survivors are more likely to require hospitalization and experience a higher burden of chronic illness than the general population. Guidelines for surveillance for late effects are intended to reduce the burden of morbidity, but research is needed to determine whether such surveillance is cost effective. Of note, risk-based survivor care should include routine surveillance for financial hardship. Improved measures of financial hardship, enhanced data infrastructure, and research studies to identify survivors and families most vulnerable to financial hardship and adverse health outcomes will inform the development of targeted programs to serve as a safety net for those at greatest risk.
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Affiliation(s)
- Paul C. Nathan
- Paul C. Nathan, The Hospital for Sick Children, Toronto, Ontario, Canada; Tara O. Henderson, The University of Chicago, Chicago, IL; Anne C. Kirchhoff, University of Utah, Salt Lake City, UT; Elyse R. Park, Massachusetts General Hospital, Boston, MA; and K. Robin Yabroff, American Cancer Society, Atlanta, GA
| | - Tara O. Henderson
- Paul C. Nathan, The Hospital for Sick Children, Toronto, Ontario, Canada; Tara O. Henderson, The University of Chicago, Chicago, IL; Anne C. Kirchhoff, University of Utah, Salt Lake City, UT; Elyse R. Park, Massachusetts General Hospital, Boston, MA; and K. Robin Yabroff, American Cancer Society, Atlanta, GA
| | - Anne C. Kirchhoff
- Paul C. Nathan, The Hospital for Sick Children, Toronto, Ontario, Canada; Tara O. Henderson, The University of Chicago, Chicago, IL; Anne C. Kirchhoff, University of Utah, Salt Lake City, UT; Elyse R. Park, Massachusetts General Hospital, Boston, MA; and K. Robin Yabroff, American Cancer Society, Atlanta, GA
| | - Elyse R. Park
- Paul C. Nathan, The Hospital for Sick Children, Toronto, Ontario, Canada; Tara O. Henderson, The University of Chicago, Chicago, IL; Anne C. Kirchhoff, University of Utah, Salt Lake City, UT; Elyse R. Park, Massachusetts General Hospital, Boston, MA; and K. Robin Yabroff, American Cancer Society, Atlanta, GA
| | - K. Robin Yabroff
- Paul C. Nathan, The Hospital for Sick Children, Toronto, Ontario, Canada; Tara O. Henderson, The University of Chicago, Chicago, IL; Anne C. Kirchhoff, University of Utah, Salt Lake City, UT; Elyse R. Park, Massachusetts General Hospital, Boston, MA; and K. Robin Yabroff, American Cancer Society, Atlanta, GA
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Utility of Echocardiography as Screening for Late-onset Anthracycline-induced Cardiotoxicity in Pediatric Cancer Survivors: Observations from the First Decade After End of Therapy. J Pediatr Hematol Oncol 2018; 40:e283-e288. [PMID: 29432303 DOI: 10.1097/mph.0000000000001087] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Current screening guidelines are available for anthracycline-induced cardiotoxicity. However, the utility of echocardiogram screening for late-onset anthracycline cardiotoxicity especially in the decade immediately after end of therapy is debatable. A retrospective chart review of patients seen in the Thriving after Cancer Clinic at Rady Children's Hospital January 2006 to December 2013 was performed. Treatment data, echocardiogram results, cardiology referral notes and cardiac medication data were abstracted from anthracycline-exposed survivors. Descriptive and univariate comparative statistics were performed. Of 368 patients (45% female, median 5.3 y old at diagnosis [range 0 to 18.3], median 5.0 y from end of therapy [EOT] [range 0 to 18.2]), a total of 4 patients (10-year cumulative incidence after EOT 1.3%; 95% confidence interval, 0.1%-19.7%) required cardiac medication for late-onset cardiotoxicity (>1 y after EOT). Those requiring medication for late-onset cardiotoxicity were exposed to more anthracyclines than survivors without cardiotoxicity (median, 360 mg/m [range, 300 to 375 mg/m] vs. 182 mg/m [range, 26 to 515 mg/m], P=0.009). None had neck or chest radiation. In this population, medication initiation for late-onset anthracycline cardiotoxicity was limited predominantly to the first 3 years after EOT, with the next >13 years after EOT. These findings add to the growing body of literature assessing current guidelines to inform improvements in screening practices of survivorship providers.
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Armenian SH, Rinderknecht D, Au K, Lindenfeld L, Mills G, Siyahian A, Herrera C, Wilson K, Venkataraman K, Mascarenhas K, Tavallali P, Razavi M, Pahlevan N, Detterich J, Bhatia S, Gharib M. Accuracy of a Novel Handheld Wireless Platform for Detection of Cardiac Dysfunction in Anthracycline-Exposed Survivors of Childhood Cancer. Clin Cancer Res 2018; 24:3119-3125. [DOI: 10.1158/1078-0432.ccr-17-3599] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2017] [Revised: 01/15/2018] [Accepted: 03/06/2018] [Indexed: 11/16/2022]
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Gibson TM, Li C, Armstrong GT, Srivastava DK, Leisenring WM, Mertens A, Brinkman TM, Diller L, Nathan PC, Hudson MM, Robison LL. Perceptions of future health and cancer risk in adult survivors of childhood cancer: A report from the Childhood Cancer Survivor Study. Cancer 2018; 124:3436-3444. [PMID: 29938398 DOI: 10.1002/cncr.31397] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2018] [Revised: 03/16/2018] [Accepted: 03/20/2018] [Indexed: 12/18/2022]
Abstract
BACKGROUND Survivors of childhood cancer are at significant risk for serious chronic health conditions and subsequent cancers because of their prior treatment exposures. However, little is known about survivors' perceptions of their future health risks. METHODS This study examined self-reported levels of concern about future health and subsequent cancer in 15,620 adult survivors of childhood cancer (median age, 26 years; median time since diagnosis, 17 years) and 3991 siblings in the Childhood Cancer Survivor Study. The prevalence of concerns was compared between survivors and siblings, and the impact of participant characteristics and treatment exposures on concerns was examined with multivariable modified Poisson regression to estimate relative risks (RRs) and 95% confidence intervals (CIs). RESULTS A substantial proportion of survivors were not concerned about their future health (31%) or developing cancer (40%). The prevalence of concern in survivors was modestly higher (RR for future health, 1.12; 95% CI, 1.09-1.15) or similar (RR for subsequent cancer, 1.02; 95% CI, 0.99-1.05) in comparison with siblings. Survivors exposed to high doses of radiation (≥20 Gy) were more likely to report concern (RR for future health, 1.13; 95% CI, 1.09-1.16; RR for subsequent cancer, 1.14; 95% CI, 1.10-1.18), but 35% of these high-risk survivors were not concerned about developing cancer, and 24% were not concerned about their future health. CONCLUSIONS A substantial subgroup of survivors were unconcerned about their future health and subsequent cancer risks, even after exposure to treatments associated with increased risk. These survivors may be less likely to engage in beneficial screening and risk-reduction activities. Cancer 2018. © 2018 American Cancer Society.
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Affiliation(s)
- Todd M Gibson
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Chenghong Li
- Department of Biostatistics, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Gregory T Armstrong
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Deo Kumar Srivastava
- Department of Biostatistics, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Wendy M Leisenring
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Ann Mertens
- Department of Pediatrics, Emory University, Atlanta, Georgia
| | - Tara M Brinkman
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Lisa Diller
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center and Harvard Medical School, Boston, Massachusetts
| | - Paul C Nathan
- Division of Hematology/Oncology, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Melissa M Hudson
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Leslie L Robison
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, Tennessee
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Pettit SD, Kirch R. Do current approaches to assessing therapy related adverse events align with the needs of long-term cancer patients and survivors? CARDIO-ONCOLOGY (LONDON, ENGLAND) 2018; 4:5. [PMID: 32154005 PMCID: PMC7048033 DOI: 10.1186/s40959-018-0031-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Accepted: 05/30/2018] [Indexed: 01/29/2023]
Abstract
The increasing efficacy of cancer therapeutics means that the timespan of cancer therapy administration is undergoing a transition to increasingly long-term settings. Unfortunately, chronic therapy-related adverse health events are an unintended, but not infrequent, outcome of these life-saving therapies. Historically, the cardio-oncology field has evolved as retrospective effort to understand the scope, mechanisms, and impact of treatment-related toxicities that were already impacting patients. This review explores whether current systemic approaches to detecting, reporting, tracking, and communicating AEs are better positioned to provide more proactive or concurrent information to mitigate the impact of AE's on patient health and quality of life. Because the existing tools and frameworks for capturing these effects are not specific to cardiology, this study looks broadly at the landscape of approaches and assumptions. This review finds evidence of increasing focus on the provision of actionable information to support long-term health and quality of life for survivors and those on chronic therapy. However, the current means to assess and support the impact of this burden on patients and the healthcare system are often of limited relevance for an increasingly long-lived survivor and patient population.
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Affiliation(s)
- Syril D. Pettit
- Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC USA
- Health and Environmental Sciences Institute, Washington DC, USA
| | - Rebecca Kirch
- National Patient Advocate Foundation, Washington DC, USA
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Landier W, Skinner R, Wallace WH, Hjorth L, Mulder RL, Wong FL, Yasui Y, Bhakta N, Constine LS, Bhatia S, Kremer LC, Hudson MM. Surveillance for Late Effects in Childhood Cancer Survivors. J Clin Oncol 2018; 36:2216-2222. [PMID: 29874139 DOI: 10.1200/jco.2017.77.0180] [Citation(s) in RCA: 115] [Impact Index Per Article: 19.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Many childhood cancer survivors carry a significant risk for late morbidity and mortality, a consequence of the numerous therapeutic exposures that contribute to their cure. Focused surveillance for late therapy-related complications provides opportunities for early detection and implementation of health-preserving interventions. The substantial body of research that links therapeutic exposures used during treatment of childhood cancer to adverse outcomes among survivors enables the characterization of groups at the highest risk for developing complications related to specific therapies; however, methods available to optimize screening strategies to detect these therapy-related complications are limited. Moreover, the feasibility of conducting clinical trials to test screening recommendations for childhood cancer survivors is limited by requirements for large sample sizes, lengthy study periods, prohibitive costs, and ethical concerns. In addition, the harms of screening should be considered, including overdiagnosis and psychological distress. Experts in several countries have developed guideline recommendations for late effects surveillance and have collaborated to harmonize these recommendations internationally to enhance long-term follow-up care and quality of life for childhood cancer survivors. Methods used in these international efforts include systematic literature searches, development of evidence-based summaries, rigorous evaluation of the evidence, and formulation of consensus-based surveillance recommendations for each late complication. Alternate methods to refine recommendations, such as cumulative burden assessment and risk prediction and cost-effectiveness modeling, may provide novel approaches to guide survivorship care in this vulnerable population and, thus, represents a worthy objective for future international survivorship collaborations.
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Affiliation(s)
- Wendy Landier
- Wendy Landier and Smita Bhatia, University of Alabama at Birmingham, Birmingham, AL; Roderick Skinner, University of Newcastle upon Tyne, Newcastle upon Tyne; W. Hamish Wallace, Royal Hospital for Sick Children, Edinburgh, United Kingdom; Lars Hjorth, Skåne University Hospital, Lund, Sweden; Renée L. Mulder and Leontien C. Kremer, Emma Children's Hospital, Amsterdam; Leontien C. Kremer, Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands; F. Lennie Wong, City of Hope, Duarte, CA; Yutaka Yasui, Nickhill Bhakta, and Melissa M. Hudson, St Jude Children's Research Hospital, Memphis, TN; and Louis S. Constine, University of Rochester Medical Center, Rochester, NY
| | - Roderick Skinner
- Wendy Landier and Smita Bhatia, University of Alabama at Birmingham, Birmingham, AL; Roderick Skinner, University of Newcastle upon Tyne, Newcastle upon Tyne; W. Hamish Wallace, Royal Hospital for Sick Children, Edinburgh, United Kingdom; Lars Hjorth, Skåne University Hospital, Lund, Sweden; Renée L. Mulder and Leontien C. Kremer, Emma Children's Hospital, Amsterdam; Leontien C. Kremer, Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands; F. Lennie Wong, City of Hope, Duarte, CA; Yutaka Yasui, Nickhill Bhakta, and Melissa M. Hudson, St Jude Children's Research Hospital, Memphis, TN; and Louis S. Constine, University of Rochester Medical Center, Rochester, NY
| | - W Hamish Wallace
- Wendy Landier and Smita Bhatia, University of Alabama at Birmingham, Birmingham, AL; Roderick Skinner, University of Newcastle upon Tyne, Newcastle upon Tyne; W. Hamish Wallace, Royal Hospital for Sick Children, Edinburgh, United Kingdom; Lars Hjorth, Skåne University Hospital, Lund, Sweden; Renée L. Mulder and Leontien C. Kremer, Emma Children's Hospital, Amsterdam; Leontien C. Kremer, Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands; F. Lennie Wong, City of Hope, Duarte, CA; Yutaka Yasui, Nickhill Bhakta, and Melissa M. Hudson, St Jude Children's Research Hospital, Memphis, TN; and Louis S. Constine, University of Rochester Medical Center, Rochester, NY
| | - Lars Hjorth
- Wendy Landier and Smita Bhatia, University of Alabama at Birmingham, Birmingham, AL; Roderick Skinner, University of Newcastle upon Tyne, Newcastle upon Tyne; W. Hamish Wallace, Royal Hospital for Sick Children, Edinburgh, United Kingdom; Lars Hjorth, Skåne University Hospital, Lund, Sweden; Renée L. Mulder and Leontien C. Kremer, Emma Children's Hospital, Amsterdam; Leontien C. Kremer, Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands; F. Lennie Wong, City of Hope, Duarte, CA; Yutaka Yasui, Nickhill Bhakta, and Melissa M. Hudson, St Jude Children's Research Hospital, Memphis, TN; and Louis S. Constine, University of Rochester Medical Center, Rochester, NY
| | - Renée L Mulder
- Wendy Landier and Smita Bhatia, University of Alabama at Birmingham, Birmingham, AL; Roderick Skinner, University of Newcastle upon Tyne, Newcastle upon Tyne; W. Hamish Wallace, Royal Hospital for Sick Children, Edinburgh, United Kingdom; Lars Hjorth, Skåne University Hospital, Lund, Sweden; Renée L. Mulder and Leontien C. Kremer, Emma Children's Hospital, Amsterdam; Leontien C. Kremer, Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands; F. Lennie Wong, City of Hope, Duarte, CA; Yutaka Yasui, Nickhill Bhakta, and Melissa M. Hudson, St Jude Children's Research Hospital, Memphis, TN; and Louis S. Constine, University of Rochester Medical Center, Rochester, NY
| | - F Lennie Wong
- Wendy Landier and Smita Bhatia, University of Alabama at Birmingham, Birmingham, AL; Roderick Skinner, University of Newcastle upon Tyne, Newcastle upon Tyne; W. Hamish Wallace, Royal Hospital for Sick Children, Edinburgh, United Kingdom; Lars Hjorth, Skåne University Hospital, Lund, Sweden; Renée L. Mulder and Leontien C. Kremer, Emma Children's Hospital, Amsterdam; Leontien C. Kremer, Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands; F. Lennie Wong, City of Hope, Duarte, CA; Yutaka Yasui, Nickhill Bhakta, and Melissa M. Hudson, St Jude Children's Research Hospital, Memphis, TN; and Louis S. Constine, University of Rochester Medical Center, Rochester, NY
| | - Yutaka Yasui
- Wendy Landier and Smita Bhatia, University of Alabama at Birmingham, Birmingham, AL; Roderick Skinner, University of Newcastle upon Tyne, Newcastle upon Tyne; W. Hamish Wallace, Royal Hospital for Sick Children, Edinburgh, United Kingdom; Lars Hjorth, Skåne University Hospital, Lund, Sweden; Renée L. Mulder and Leontien C. Kremer, Emma Children's Hospital, Amsterdam; Leontien C. Kremer, Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands; F. Lennie Wong, City of Hope, Duarte, CA; Yutaka Yasui, Nickhill Bhakta, and Melissa M. Hudson, St Jude Children's Research Hospital, Memphis, TN; and Louis S. Constine, University of Rochester Medical Center, Rochester, NY
| | - Nickhill Bhakta
- Wendy Landier and Smita Bhatia, University of Alabama at Birmingham, Birmingham, AL; Roderick Skinner, University of Newcastle upon Tyne, Newcastle upon Tyne; W. Hamish Wallace, Royal Hospital for Sick Children, Edinburgh, United Kingdom; Lars Hjorth, Skåne University Hospital, Lund, Sweden; Renée L. Mulder and Leontien C. Kremer, Emma Children's Hospital, Amsterdam; Leontien C. Kremer, Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands; F. Lennie Wong, City of Hope, Duarte, CA; Yutaka Yasui, Nickhill Bhakta, and Melissa M. Hudson, St Jude Children's Research Hospital, Memphis, TN; and Louis S. Constine, University of Rochester Medical Center, Rochester, NY
| | - Louis S Constine
- Wendy Landier and Smita Bhatia, University of Alabama at Birmingham, Birmingham, AL; Roderick Skinner, University of Newcastle upon Tyne, Newcastle upon Tyne; W. Hamish Wallace, Royal Hospital for Sick Children, Edinburgh, United Kingdom; Lars Hjorth, Skåne University Hospital, Lund, Sweden; Renée L. Mulder and Leontien C. Kremer, Emma Children's Hospital, Amsterdam; Leontien C. Kremer, Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands; F. Lennie Wong, City of Hope, Duarte, CA; Yutaka Yasui, Nickhill Bhakta, and Melissa M. Hudson, St Jude Children's Research Hospital, Memphis, TN; and Louis S. Constine, University of Rochester Medical Center, Rochester, NY
| | - Smita Bhatia
- Wendy Landier and Smita Bhatia, University of Alabama at Birmingham, Birmingham, AL; Roderick Skinner, University of Newcastle upon Tyne, Newcastle upon Tyne; W. Hamish Wallace, Royal Hospital for Sick Children, Edinburgh, United Kingdom; Lars Hjorth, Skåne University Hospital, Lund, Sweden; Renée L. Mulder and Leontien C. Kremer, Emma Children's Hospital, Amsterdam; Leontien C. Kremer, Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands; F. Lennie Wong, City of Hope, Duarte, CA; Yutaka Yasui, Nickhill Bhakta, and Melissa M. Hudson, St Jude Children's Research Hospital, Memphis, TN; and Louis S. Constine, University of Rochester Medical Center, Rochester, NY
| | - Leontien C Kremer
- Wendy Landier and Smita Bhatia, University of Alabama at Birmingham, Birmingham, AL; Roderick Skinner, University of Newcastle upon Tyne, Newcastle upon Tyne; W. Hamish Wallace, Royal Hospital for Sick Children, Edinburgh, United Kingdom; Lars Hjorth, Skåne University Hospital, Lund, Sweden; Renée L. Mulder and Leontien C. Kremer, Emma Children's Hospital, Amsterdam; Leontien C. Kremer, Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands; F. Lennie Wong, City of Hope, Duarte, CA; Yutaka Yasui, Nickhill Bhakta, and Melissa M. Hudson, St Jude Children's Research Hospital, Memphis, TN; and Louis S. Constine, University of Rochester Medical Center, Rochester, NY
| | - Melissa M Hudson
- Wendy Landier and Smita Bhatia, University of Alabama at Birmingham, Birmingham, AL; Roderick Skinner, University of Newcastle upon Tyne, Newcastle upon Tyne; W. Hamish Wallace, Royal Hospital for Sick Children, Edinburgh, United Kingdom; Lars Hjorth, Skåne University Hospital, Lund, Sweden; Renée L. Mulder and Leontien C. Kremer, Emma Children's Hospital, Amsterdam; Leontien C. Kremer, Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands; F. Lennie Wong, City of Hope, Duarte, CA; Yutaka Yasui, Nickhill Bhakta, and Melissa M. Hudson, St Jude Children's Research Hospital, Memphis, TN; and Louis S. Constine, University of Rochester Medical Center, Rochester, NY
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Armenian SH, Armstrong GT, Aune G, Chow EJ, Ehrhardt MJ, Ky B, Moslehi J, Mulrooney DA, Nathan PC, Ryan TD, van der Pal HJ, van Dalen EC, Kremer LCM. Cardiovascular Disease in Survivors of Childhood Cancer: Insights Into Epidemiology, Pathophysiology, and Prevention. J Clin Oncol 2018; 36:2135-2144. [PMID: 29874141 DOI: 10.1200/jco.2017.76.3920] [Citation(s) in RCA: 131] [Impact Index Per Article: 21.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Cardiovascular disease (CVD), which includes cardiomyopathy/heart failure, coronary artery disease, stroke, pericardial disease, arrhythmias, and valvular and vascular dysfunction, is a major concern for long-term survivors of childhood cancer. There is clear evidence of increased risk of CVD largely attributable to treatment exposures at a young age, most notably anthracycline chemotherapy and chest-directed radiation therapy, and compounded by traditional cardiovascular risk factors accrued during decades after treatment exposure. Preclinical studies are limited; thus, it is a high priority to understand the pathophysiology of CVD as a result of anticancer treatments, taking into consideration the growing and developing heart. Recently developed personalized risk prediction models can provide decision support before initiation of anticancer therapy or facilitate implementation of screening strategies in at-risk survivors of cancer. Although consensus-based screening guidelines exist for the application of blood and imaging biomarkers of CVD, the most appropriate timing and frequency of these measures in survivors of childhood cancer are not yet fully elucidated. Longitudinal studies are needed to characterize the prognostic importance of subclinical markers of cardiovascular injury on long-term CVD risk. A number of prevention trials across the survivorship spectrum are under way, which include primary prevention (before or during cancer treatment), secondary prevention (after completion of treatment), and integrated approaches to manage modifiable cardiovascular risk factors. Ongoing multidisciplinary collaborations between the oncology, cardiology, primary care, and other subspecialty communities are essential to reduce therapeutic exposures and improve surveillance, prevention, and treatment of CVD in this high-risk population.
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Affiliation(s)
- Saro H Armenian
- Saro H. Armenian, City of Hope, Duarte, CA; Gregory T. Armstrong, Matthew J. Ehrhardt, and Daniel A. Mulrooney, St Jude Children's Research Hospital, Memphis; Javid Moslehi, Vanderbilt School of Medicine, Nashville, TN; Gregory Aune, Greehey Children's Cancer Research Institute, University of Texas Health Science Center at San Antonio, San Antonio, TX; Eric J. Chow, Fred Hutchinson Cancer Research Center, Seattle, WA; Bonnie Ky, University of Pennsylvania, Philadelphia, PA; Paul C. Nathan, The Hospital for Sick Children, Toronto, Ontario, Canada; Thomas D. Ryan, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Helena J. van der Pal and Leontien C.M. Kremer, Princess Máxima Center for Pediatric Oncology, Utrecht; and Elvira C. van Dalen and Leontien C.M. Kremer, Emma Children's Hospital/Academic Medical Center, Amsterdam, the Netherlands
| | - Gregory T Armstrong
- Saro H. Armenian, City of Hope, Duarte, CA; Gregory T. Armstrong, Matthew J. Ehrhardt, and Daniel A. Mulrooney, St Jude Children's Research Hospital, Memphis; Javid Moslehi, Vanderbilt School of Medicine, Nashville, TN; Gregory Aune, Greehey Children's Cancer Research Institute, University of Texas Health Science Center at San Antonio, San Antonio, TX; Eric J. Chow, Fred Hutchinson Cancer Research Center, Seattle, WA; Bonnie Ky, University of Pennsylvania, Philadelphia, PA; Paul C. Nathan, The Hospital for Sick Children, Toronto, Ontario, Canada; Thomas D. Ryan, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Helena J. van der Pal and Leontien C.M. Kremer, Princess Máxima Center for Pediatric Oncology, Utrecht; and Elvira C. van Dalen and Leontien C.M. Kremer, Emma Children's Hospital/Academic Medical Center, Amsterdam, the Netherlands
| | - Gregory Aune
- Saro H. Armenian, City of Hope, Duarte, CA; Gregory T. Armstrong, Matthew J. Ehrhardt, and Daniel A. Mulrooney, St Jude Children's Research Hospital, Memphis; Javid Moslehi, Vanderbilt School of Medicine, Nashville, TN; Gregory Aune, Greehey Children's Cancer Research Institute, University of Texas Health Science Center at San Antonio, San Antonio, TX; Eric J. Chow, Fred Hutchinson Cancer Research Center, Seattle, WA; Bonnie Ky, University of Pennsylvania, Philadelphia, PA; Paul C. Nathan, The Hospital for Sick Children, Toronto, Ontario, Canada; Thomas D. Ryan, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Helena J. van der Pal and Leontien C.M. Kremer, Princess Máxima Center for Pediatric Oncology, Utrecht; and Elvira C. van Dalen and Leontien C.M. Kremer, Emma Children's Hospital/Academic Medical Center, Amsterdam, the Netherlands
| | - Eric J Chow
- Saro H. Armenian, City of Hope, Duarte, CA; Gregory T. Armstrong, Matthew J. Ehrhardt, and Daniel A. Mulrooney, St Jude Children's Research Hospital, Memphis; Javid Moslehi, Vanderbilt School of Medicine, Nashville, TN; Gregory Aune, Greehey Children's Cancer Research Institute, University of Texas Health Science Center at San Antonio, San Antonio, TX; Eric J. Chow, Fred Hutchinson Cancer Research Center, Seattle, WA; Bonnie Ky, University of Pennsylvania, Philadelphia, PA; Paul C. Nathan, The Hospital for Sick Children, Toronto, Ontario, Canada; Thomas D. Ryan, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Helena J. van der Pal and Leontien C.M. Kremer, Princess Máxima Center for Pediatric Oncology, Utrecht; and Elvira C. van Dalen and Leontien C.M. Kremer, Emma Children's Hospital/Academic Medical Center, Amsterdam, the Netherlands
| | - Matthew J Ehrhardt
- Saro H. Armenian, City of Hope, Duarte, CA; Gregory T. Armstrong, Matthew J. Ehrhardt, and Daniel A. Mulrooney, St Jude Children's Research Hospital, Memphis; Javid Moslehi, Vanderbilt School of Medicine, Nashville, TN; Gregory Aune, Greehey Children's Cancer Research Institute, University of Texas Health Science Center at San Antonio, San Antonio, TX; Eric J. Chow, Fred Hutchinson Cancer Research Center, Seattle, WA; Bonnie Ky, University of Pennsylvania, Philadelphia, PA; Paul C. Nathan, The Hospital for Sick Children, Toronto, Ontario, Canada; Thomas D. Ryan, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Helena J. van der Pal and Leontien C.M. Kremer, Princess Máxima Center for Pediatric Oncology, Utrecht; and Elvira C. van Dalen and Leontien C.M. Kremer, Emma Children's Hospital/Academic Medical Center, Amsterdam, the Netherlands
| | - Bonnie Ky
- Saro H. Armenian, City of Hope, Duarte, CA; Gregory T. Armstrong, Matthew J. Ehrhardt, and Daniel A. Mulrooney, St Jude Children's Research Hospital, Memphis; Javid Moslehi, Vanderbilt School of Medicine, Nashville, TN; Gregory Aune, Greehey Children's Cancer Research Institute, University of Texas Health Science Center at San Antonio, San Antonio, TX; Eric J. Chow, Fred Hutchinson Cancer Research Center, Seattle, WA; Bonnie Ky, University of Pennsylvania, Philadelphia, PA; Paul C. Nathan, The Hospital for Sick Children, Toronto, Ontario, Canada; Thomas D. Ryan, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Helena J. van der Pal and Leontien C.M. Kremer, Princess Máxima Center for Pediatric Oncology, Utrecht; and Elvira C. van Dalen and Leontien C.M. Kremer, Emma Children's Hospital/Academic Medical Center, Amsterdam, the Netherlands
| | - Javid Moslehi
- Saro H. Armenian, City of Hope, Duarte, CA; Gregory T. Armstrong, Matthew J. Ehrhardt, and Daniel A. Mulrooney, St Jude Children's Research Hospital, Memphis; Javid Moslehi, Vanderbilt School of Medicine, Nashville, TN; Gregory Aune, Greehey Children's Cancer Research Institute, University of Texas Health Science Center at San Antonio, San Antonio, TX; Eric J. Chow, Fred Hutchinson Cancer Research Center, Seattle, WA; Bonnie Ky, University of Pennsylvania, Philadelphia, PA; Paul C. Nathan, The Hospital for Sick Children, Toronto, Ontario, Canada; Thomas D. Ryan, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Helena J. van der Pal and Leontien C.M. Kremer, Princess Máxima Center for Pediatric Oncology, Utrecht; and Elvira C. van Dalen and Leontien C.M. Kremer, Emma Children's Hospital/Academic Medical Center, Amsterdam, the Netherlands
| | - Daniel A Mulrooney
- Saro H. Armenian, City of Hope, Duarte, CA; Gregory T. Armstrong, Matthew J. Ehrhardt, and Daniel A. Mulrooney, St Jude Children's Research Hospital, Memphis; Javid Moslehi, Vanderbilt School of Medicine, Nashville, TN; Gregory Aune, Greehey Children's Cancer Research Institute, University of Texas Health Science Center at San Antonio, San Antonio, TX; Eric J. Chow, Fred Hutchinson Cancer Research Center, Seattle, WA; Bonnie Ky, University of Pennsylvania, Philadelphia, PA; Paul C. Nathan, The Hospital for Sick Children, Toronto, Ontario, Canada; Thomas D. Ryan, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Helena J. van der Pal and Leontien C.M. Kremer, Princess Máxima Center for Pediatric Oncology, Utrecht; and Elvira C. van Dalen and Leontien C.M. Kremer, Emma Children's Hospital/Academic Medical Center, Amsterdam, the Netherlands
| | - Paul C Nathan
- Saro H. Armenian, City of Hope, Duarte, CA; Gregory T. Armstrong, Matthew J. Ehrhardt, and Daniel A. Mulrooney, St Jude Children's Research Hospital, Memphis; Javid Moslehi, Vanderbilt School of Medicine, Nashville, TN; Gregory Aune, Greehey Children's Cancer Research Institute, University of Texas Health Science Center at San Antonio, San Antonio, TX; Eric J. Chow, Fred Hutchinson Cancer Research Center, Seattle, WA; Bonnie Ky, University of Pennsylvania, Philadelphia, PA; Paul C. Nathan, The Hospital for Sick Children, Toronto, Ontario, Canada; Thomas D. Ryan, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Helena J. van der Pal and Leontien C.M. Kremer, Princess Máxima Center for Pediatric Oncology, Utrecht; and Elvira C. van Dalen and Leontien C.M. Kremer, Emma Children's Hospital/Academic Medical Center, Amsterdam, the Netherlands
| | - Thomas D Ryan
- Saro H. Armenian, City of Hope, Duarte, CA; Gregory T. Armstrong, Matthew J. Ehrhardt, and Daniel A. Mulrooney, St Jude Children's Research Hospital, Memphis; Javid Moslehi, Vanderbilt School of Medicine, Nashville, TN; Gregory Aune, Greehey Children's Cancer Research Institute, University of Texas Health Science Center at San Antonio, San Antonio, TX; Eric J. Chow, Fred Hutchinson Cancer Research Center, Seattle, WA; Bonnie Ky, University of Pennsylvania, Philadelphia, PA; Paul C. Nathan, The Hospital for Sick Children, Toronto, Ontario, Canada; Thomas D. Ryan, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Helena J. van der Pal and Leontien C.M. Kremer, Princess Máxima Center for Pediatric Oncology, Utrecht; and Elvira C. van Dalen and Leontien C.M. Kremer, Emma Children's Hospital/Academic Medical Center, Amsterdam, the Netherlands
| | - Helena J van der Pal
- Saro H. Armenian, City of Hope, Duarte, CA; Gregory T. Armstrong, Matthew J. Ehrhardt, and Daniel A. Mulrooney, St Jude Children's Research Hospital, Memphis; Javid Moslehi, Vanderbilt School of Medicine, Nashville, TN; Gregory Aune, Greehey Children's Cancer Research Institute, University of Texas Health Science Center at San Antonio, San Antonio, TX; Eric J. Chow, Fred Hutchinson Cancer Research Center, Seattle, WA; Bonnie Ky, University of Pennsylvania, Philadelphia, PA; Paul C. Nathan, The Hospital for Sick Children, Toronto, Ontario, Canada; Thomas D. Ryan, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Helena J. van der Pal and Leontien C.M. Kremer, Princess Máxima Center for Pediatric Oncology, Utrecht; and Elvira C. van Dalen and Leontien C.M. Kremer, Emma Children's Hospital/Academic Medical Center, Amsterdam, the Netherlands
| | - Elvira C van Dalen
- Saro H. Armenian, City of Hope, Duarte, CA; Gregory T. Armstrong, Matthew J. Ehrhardt, and Daniel A. Mulrooney, St Jude Children's Research Hospital, Memphis; Javid Moslehi, Vanderbilt School of Medicine, Nashville, TN; Gregory Aune, Greehey Children's Cancer Research Institute, University of Texas Health Science Center at San Antonio, San Antonio, TX; Eric J. Chow, Fred Hutchinson Cancer Research Center, Seattle, WA; Bonnie Ky, University of Pennsylvania, Philadelphia, PA; Paul C. Nathan, The Hospital for Sick Children, Toronto, Ontario, Canada; Thomas D. Ryan, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Helena J. van der Pal and Leontien C.M. Kremer, Princess Máxima Center for Pediatric Oncology, Utrecht; and Elvira C. van Dalen and Leontien C.M. Kremer, Emma Children's Hospital/Academic Medical Center, Amsterdam, the Netherlands
| | - Leontien C M Kremer
- Saro H. Armenian, City of Hope, Duarte, CA; Gregory T. Armstrong, Matthew J. Ehrhardt, and Daniel A. Mulrooney, St Jude Children's Research Hospital, Memphis; Javid Moslehi, Vanderbilt School of Medicine, Nashville, TN; Gregory Aune, Greehey Children's Cancer Research Institute, University of Texas Health Science Center at San Antonio, San Antonio, TX; Eric J. Chow, Fred Hutchinson Cancer Research Center, Seattle, WA; Bonnie Ky, University of Pennsylvania, Philadelphia, PA; Paul C. Nathan, The Hospital for Sick Children, Toronto, Ontario, Canada; Thomas D. Ryan, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Helena J. van der Pal and Leontien C.M. Kremer, Princess Máxima Center for Pediatric Oncology, Utrecht; and Elvira C. van Dalen and Leontien C.M. Kremer, Emma Children's Hospital/Academic Medical Center, Amsterdam, the Netherlands
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Tonorezos ES, Barnea D, Cohn RJ, Cypriano MS, Fresneau BC, Haupt R, Hjorth L, Ishida Y, Kruseova J, Kuehni CE, Kurkure PA, Langer T, Nathan PC, Skeen JE, Skinner R, Tacyildiz N, van den Heuvel-Eibrink MM, Winther JF, Hudson MM, Oeffinger KC. Models of Care for Survivors of Childhood Cancer From Across the Globe: Advancing Survivorship Care in the Next Decade. J Clin Oncol 2018; 36:2223-2230. [PMID: 29874138 DOI: 10.1200/jco.2017.76.5180] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
With improvements in cancer treatment and supportive care, a growing population of survivors of childhood cancer at risk for significant and potentially life-threatening late effects has been identified. To provide a current snapshot of the models of care from countries with varying levels of resources and health care systems, stakeholders in childhood cancer survivorship clinical care and research were identified from 18 countries across five continents. Stakeholders responded to a survey and provided a brief narrative regarding the current state of survivorship care. Findings indicate that among pediatric-age survivors of childhood cancer (allowing for differences in age cutoffs across countries), resources are generally available, and a large proportion of survivors are seen by a physician familiar with late effects in most countries. After survivors transition to adulthood, only a minority are seen by a physician familiar with late effects. Despite the need to improve communication between pediatric oncology and primary care, only a few countries have existing national efforts to educate primary care physicians, although many more reported that educational programs are in development. These data highlight common challenges and potential solutions for the lifelong care of survivors of childhood cancer. Combining risk-based and patient-oriented solutions for this population is likely to benefit both providers and patients.
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Affiliation(s)
- Emily S Tonorezos
- Emily S. Tonorezos, Memorial Sloan Kettering Cancer Center, New York, NY; Dana Barnea, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel; Richard J. Cohn, Sydney Children's Hospital, and University of New South Wales Medicine, Sydney, New South Wales, Australia; Monica S. Cypriano, Grupo de Apoio ao Adolescente e Criança com Câncer (GRAACC)/Universidade Federal de São Paulo, São Paulo, Brazil; Brice C. Fresneau, Gustave Roussy, Université Paris-Saclay, Paris-Sud University, Centre for Research in Epidemiology and Population Health (CESP), and L'Institut National de la Santé et de la Recherche Médicale, Villejuif, France; Riccardo Haupt, Istituto Giannina Gaslini, Genoa, Italy; Lars Hjorth, Lund University, Skane University Hospital, Lund, Sweden; Yasushi Ishida, Ehime Prefectural Central Hospital, Matsuyama, Japan; Jarmila Kruseova, Charles University, Prague, Czech Republic; Claudia E. Kuehni, University of Bern, Bern, Switzerland; Purna A. Kurkure, Society for Rehabilitation of Crippled Children (SRCC) Children's Hospital, Indian Cancer Society, and Tata Memorial Hospital, Mumbai, India; Thorsten Langer, University Hospital, Luebeck, Germany; Paul C. Nathan, The Hospital for Sick Children, The University of Toronto, Toronto, Ontario, Canada; Jane E. Skeen, Starship Children's Hospital, Auckland, New Zealand; Roderick Skinner, Great North Children's Hospital, Newcastle upon Tyne Hospitals National Health Service Foundation Trust, and Newcastle University, Newcastle upon Tyne, United Kingdom; Nurdan Tacyildiz, Ankara University School of Medicine, Ankara, Turkey; Marry M. van den Heuvel-Eibrink, Princess Máxima Center, Utrecht, and Dutch Childhood Oncology Group Long-Term Effects After Childhood Cancer (LATER) Group, The Hague, the Netherlands; Jeanette F. Winther, Danish Cancer Society Research Center, Copenhagen, and Aarhus University, Aarhus, Denmark; Melissa M. Hudson, St Jude Children's Research Hospital, Memphis, TN; and Kevin C. Oeffinger, Duke University, Durham, NC
| | - Dana Barnea
- Emily S. Tonorezos, Memorial Sloan Kettering Cancer Center, New York, NY; Dana Barnea, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel; Richard J. Cohn, Sydney Children's Hospital, and University of New South Wales Medicine, Sydney, New South Wales, Australia; Monica S. Cypriano, Grupo de Apoio ao Adolescente e Criança com Câncer (GRAACC)/Universidade Federal de São Paulo, São Paulo, Brazil; Brice C. Fresneau, Gustave Roussy, Université Paris-Saclay, Paris-Sud University, Centre for Research in Epidemiology and Population Health (CESP), and L'Institut National de la Santé et de la Recherche Médicale, Villejuif, France; Riccardo Haupt, Istituto Giannina Gaslini, Genoa, Italy; Lars Hjorth, Lund University, Skane University Hospital, Lund, Sweden; Yasushi Ishida, Ehime Prefectural Central Hospital, Matsuyama, Japan; Jarmila Kruseova, Charles University, Prague, Czech Republic; Claudia E. Kuehni, University of Bern, Bern, Switzerland; Purna A. Kurkure, Society for Rehabilitation of Crippled Children (SRCC) Children's Hospital, Indian Cancer Society, and Tata Memorial Hospital, Mumbai, India; Thorsten Langer, University Hospital, Luebeck, Germany; Paul C. Nathan, The Hospital for Sick Children, The University of Toronto, Toronto, Ontario, Canada; Jane E. Skeen, Starship Children's Hospital, Auckland, New Zealand; Roderick Skinner, Great North Children's Hospital, Newcastle upon Tyne Hospitals National Health Service Foundation Trust, and Newcastle University, Newcastle upon Tyne, United Kingdom; Nurdan Tacyildiz, Ankara University School of Medicine, Ankara, Turkey; Marry M. van den Heuvel-Eibrink, Princess Máxima Center, Utrecht, and Dutch Childhood Oncology Group Long-Term Effects After Childhood Cancer (LATER) Group, The Hague, the Netherlands; Jeanette F. Winther, Danish Cancer Society Research Center, Copenhagen, and Aarhus University, Aarhus, Denmark; Melissa M. Hudson, St Jude Children's Research Hospital, Memphis, TN; and Kevin C. Oeffinger, Duke University, Durham, NC
| | - Richard J Cohn
- Emily S. Tonorezos, Memorial Sloan Kettering Cancer Center, New York, NY; Dana Barnea, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel; Richard J. Cohn, Sydney Children's Hospital, and University of New South Wales Medicine, Sydney, New South Wales, Australia; Monica S. Cypriano, Grupo de Apoio ao Adolescente e Criança com Câncer (GRAACC)/Universidade Federal de São Paulo, São Paulo, Brazil; Brice C. Fresneau, Gustave Roussy, Université Paris-Saclay, Paris-Sud University, Centre for Research in Epidemiology and Population Health (CESP), and L'Institut National de la Santé et de la Recherche Médicale, Villejuif, France; Riccardo Haupt, Istituto Giannina Gaslini, Genoa, Italy; Lars Hjorth, Lund University, Skane University Hospital, Lund, Sweden; Yasushi Ishida, Ehime Prefectural Central Hospital, Matsuyama, Japan; Jarmila Kruseova, Charles University, Prague, Czech Republic; Claudia E. Kuehni, University of Bern, Bern, Switzerland; Purna A. Kurkure, Society for Rehabilitation of Crippled Children (SRCC) Children's Hospital, Indian Cancer Society, and Tata Memorial Hospital, Mumbai, India; Thorsten Langer, University Hospital, Luebeck, Germany; Paul C. Nathan, The Hospital for Sick Children, The University of Toronto, Toronto, Ontario, Canada; Jane E. Skeen, Starship Children's Hospital, Auckland, New Zealand; Roderick Skinner, Great North Children's Hospital, Newcastle upon Tyne Hospitals National Health Service Foundation Trust, and Newcastle University, Newcastle upon Tyne, United Kingdom; Nurdan Tacyildiz, Ankara University School of Medicine, Ankara, Turkey; Marry M. van den Heuvel-Eibrink, Princess Máxima Center, Utrecht, and Dutch Childhood Oncology Group Long-Term Effects After Childhood Cancer (LATER) Group, The Hague, the Netherlands; Jeanette F. Winther, Danish Cancer Society Research Center, Copenhagen, and Aarhus University, Aarhus, Denmark; Melissa M. Hudson, St Jude Children's Research Hospital, Memphis, TN; and Kevin C. Oeffinger, Duke University, Durham, NC
| | - Monica S Cypriano
- Emily S. Tonorezos, Memorial Sloan Kettering Cancer Center, New York, NY; Dana Barnea, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel; Richard J. Cohn, Sydney Children's Hospital, and University of New South Wales Medicine, Sydney, New South Wales, Australia; Monica S. Cypriano, Grupo de Apoio ao Adolescente e Criança com Câncer (GRAACC)/Universidade Federal de São Paulo, São Paulo, Brazil; Brice C. Fresneau, Gustave Roussy, Université Paris-Saclay, Paris-Sud University, Centre for Research in Epidemiology and Population Health (CESP), and L'Institut National de la Santé et de la Recherche Médicale, Villejuif, France; Riccardo Haupt, Istituto Giannina Gaslini, Genoa, Italy; Lars Hjorth, Lund University, Skane University Hospital, Lund, Sweden; Yasushi Ishida, Ehime Prefectural Central Hospital, Matsuyama, Japan; Jarmila Kruseova, Charles University, Prague, Czech Republic; Claudia E. Kuehni, University of Bern, Bern, Switzerland; Purna A. Kurkure, Society for Rehabilitation of Crippled Children (SRCC) Children's Hospital, Indian Cancer Society, and Tata Memorial Hospital, Mumbai, India; Thorsten Langer, University Hospital, Luebeck, Germany; Paul C. Nathan, The Hospital for Sick Children, The University of Toronto, Toronto, Ontario, Canada; Jane E. Skeen, Starship Children's Hospital, Auckland, New Zealand; Roderick Skinner, Great North Children's Hospital, Newcastle upon Tyne Hospitals National Health Service Foundation Trust, and Newcastle University, Newcastle upon Tyne, United Kingdom; Nurdan Tacyildiz, Ankara University School of Medicine, Ankara, Turkey; Marry M. van den Heuvel-Eibrink, Princess Máxima Center, Utrecht, and Dutch Childhood Oncology Group Long-Term Effects After Childhood Cancer (LATER) Group, The Hague, the Netherlands; Jeanette F. Winther, Danish Cancer Society Research Center, Copenhagen, and Aarhus University, Aarhus, Denmark; Melissa M. Hudson, St Jude Children's Research Hospital, Memphis, TN; and Kevin C. Oeffinger, Duke University, Durham, NC
| | - Brice C Fresneau
- Emily S. Tonorezos, Memorial Sloan Kettering Cancer Center, New York, NY; Dana Barnea, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel; Richard J. Cohn, Sydney Children's Hospital, and University of New South Wales Medicine, Sydney, New South Wales, Australia; Monica S. Cypriano, Grupo de Apoio ao Adolescente e Criança com Câncer (GRAACC)/Universidade Federal de São Paulo, São Paulo, Brazil; Brice C. Fresneau, Gustave Roussy, Université Paris-Saclay, Paris-Sud University, Centre for Research in Epidemiology and Population Health (CESP), and L'Institut National de la Santé et de la Recherche Médicale, Villejuif, France; Riccardo Haupt, Istituto Giannina Gaslini, Genoa, Italy; Lars Hjorth, Lund University, Skane University Hospital, Lund, Sweden; Yasushi Ishida, Ehime Prefectural Central Hospital, Matsuyama, Japan; Jarmila Kruseova, Charles University, Prague, Czech Republic; Claudia E. Kuehni, University of Bern, Bern, Switzerland; Purna A. Kurkure, Society for Rehabilitation of Crippled Children (SRCC) Children's Hospital, Indian Cancer Society, and Tata Memorial Hospital, Mumbai, India; Thorsten Langer, University Hospital, Luebeck, Germany; Paul C. Nathan, The Hospital for Sick Children, The University of Toronto, Toronto, Ontario, Canada; Jane E. Skeen, Starship Children's Hospital, Auckland, New Zealand; Roderick Skinner, Great North Children's Hospital, Newcastle upon Tyne Hospitals National Health Service Foundation Trust, and Newcastle University, Newcastle upon Tyne, United Kingdom; Nurdan Tacyildiz, Ankara University School of Medicine, Ankara, Turkey; Marry M. van den Heuvel-Eibrink, Princess Máxima Center, Utrecht, and Dutch Childhood Oncology Group Long-Term Effects After Childhood Cancer (LATER) Group, The Hague, the Netherlands; Jeanette F. Winther, Danish Cancer Society Research Center, Copenhagen, and Aarhus University, Aarhus, Denmark; Melissa M. Hudson, St Jude Children's Research Hospital, Memphis, TN; and Kevin C. Oeffinger, Duke University, Durham, NC
| | - Riccardo Haupt
- Emily S. Tonorezos, Memorial Sloan Kettering Cancer Center, New York, NY; Dana Barnea, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel; Richard J. Cohn, Sydney Children's Hospital, and University of New South Wales Medicine, Sydney, New South Wales, Australia; Monica S. Cypriano, Grupo de Apoio ao Adolescente e Criança com Câncer (GRAACC)/Universidade Federal de São Paulo, São Paulo, Brazil; Brice C. Fresneau, Gustave Roussy, Université Paris-Saclay, Paris-Sud University, Centre for Research in Epidemiology and Population Health (CESP), and L'Institut National de la Santé et de la Recherche Médicale, Villejuif, France; Riccardo Haupt, Istituto Giannina Gaslini, Genoa, Italy; Lars Hjorth, Lund University, Skane University Hospital, Lund, Sweden; Yasushi Ishida, Ehime Prefectural Central Hospital, Matsuyama, Japan; Jarmila Kruseova, Charles University, Prague, Czech Republic; Claudia E. Kuehni, University of Bern, Bern, Switzerland; Purna A. Kurkure, Society for Rehabilitation of Crippled Children (SRCC) Children's Hospital, Indian Cancer Society, and Tata Memorial Hospital, Mumbai, India; Thorsten Langer, University Hospital, Luebeck, Germany; Paul C. Nathan, The Hospital for Sick Children, The University of Toronto, Toronto, Ontario, Canada; Jane E. Skeen, Starship Children's Hospital, Auckland, New Zealand; Roderick Skinner, Great North Children's Hospital, Newcastle upon Tyne Hospitals National Health Service Foundation Trust, and Newcastle University, Newcastle upon Tyne, United Kingdom; Nurdan Tacyildiz, Ankara University School of Medicine, Ankara, Turkey; Marry M. van den Heuvel-Eibrink, Princess Máxima Center, Utrecht, and Dutch Childhood Oncology Group Long-Term Effects After Childhood Cancer (LATER) Group, The Hague, the Netherlands; Jeanette F. Winther, Danish Cancer Society Research Center, Copenhagen, and Aarhus University, Aarhus, Denmark; Melissa M. Hudson, St Jude Children's Research Hospital, Memphis, TN; and Kevin C. Oeffinger, Duke University, Durham, NC
| | - Lars Hjorth
- Emily S. Tonorezos, Memorial Sloan Kettering Cancer Center, New York, NY; Dana Barnea, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel; Richard J. Cohn, Sydney Children's Hospital, and University of New South Wales Medicine, Sydney, New South Wales, Australia; Monica S. Cypriano, Grupo de Apoio ao Adolescente e Criança com Câncer (GRAACC)/Universidade Federal de São Paulo, São Paulo, Brazil; Brice C. Fresneau, Gustave Roussy, Université Paris-Saclay, Paris-Sud University, Centre for Research in Epidemiology and Population Health (CESP), and L'Institut National de la Santé et de la Recherche Médicale, Villejuif, France; Riccardo Haupt, Istituto Giannina Gaslini, Genoa, Italy; Lars Hjorth, Lund University, Skane University Hospital, Lund, Sweden; Yasushi Ishida, Ehime Prefectural Central Hospital, Matsuyama, Japan; Jarmila Kruseova, Charles University, Prague, Czech Republic; Claudia E. Kuehni, University of Bern, Bern, Switzerland; Purna A. Kurkure, Society for Rehabilitation of Crippled Children (SRCC) Children's Hospital, Indian Cancer Society, and Tata Memorial Hospital, Mumbai, India; Thorsten Langer, University Hospital, Luebeck, Germany; Paul C. Nathan, The Hospital for Sick Children, The University of Toronto, Toronto, Ontario, Canada; Jane E. Skeen, Starship Children's Hospital, Auckland, New Zealand; Roderick Skinner, Great North Children's Hospital, Newcastle upon Tyne Hospitals National Health Service Foundation Trust, and Newcastle University, Newcastle upon Tyne, United Kingdom; Nurdan Tacyildiz, Ankara University School of Medicine, Ankara, Turkey; Marry M. van den Heuvel-Eibrink, Princess Máxima Center, Utrecht, and Dutch Childhood Oncology Group Long-Term Effects After Childhood Cancer (LATER) Group, The Hague, the Netherlands; Jeanette F. Winther, Danish Cancer Society Research Center, Copenhagen, and Aarhus University, Aarhus, Denmark; Melissa M. Hudson, St Jude Children's Research Hospital, Memphis, TN; and Kevin C. Oeffinger, Duke University, Durham, NC
| | - Yasushi Ishida
- Emily S. Tonorezos, Memorial Sloan Kettering Cancer Center, New York, NY; Dana Barnea, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel; Richard J. Cohn, Sydney Children's Hospital, and University of New South Wales Medicine, Sydney, New South Wales, Australia; Monica S. Cypriano, Grupo de Apoio ao Adolescente e Criança com Câncer (GRAACC)/Universidade Federal de São Paulo, São Paulo, Brazil; Brice C. Fresneau, Gustave Roussy, Université Paris-Saclay, Paris-Sud University, Centre for Research in Epidemiology and Population Health (CESP), and L'Institut National de la Santé et de la Recherche Médicale, Villejuif, France; Riccardo Haupt, Istituto Giannina Gaslini, Genoa, Italy; Lars Hjorth, Lund University, Skane University Hospital, Lund, Sweden; Yasushi Ishida, Ehime Prefectural Central Hospital, Matsuyama, Japan; Jarmila Kruseova, Charles University, Prague, Czech Republic; Claudia E. Kuehni, University of Bern, Bern, Switzerland; Purna A. Kurkure, Society for Rehabilitation of Crippled Children (SRCC) Children's Hospital, Indian Cancer Society, and Tata Memorial Hospital, Mumbai, India; Thorsten Langer, University Hospital, Luebeck, Germany; Paul C. Nathan, The Hospital for Sick Children, The University of Toronto, Toronto, Ontario, Canada; Jane E. Skeen, Starship Children's Hospital, Auckland, New Zealand; Roderick Skinner, Great North Children's Hospital, Newcastle upon Tyne Hospitals National Health Service Foundation Trust, and Newcastle University, Newcastle upon Tyne, United Kingdom; Nurdan Tacyildiz, Ankara University School of Medicine, Ankara, Turkey; Marry M. van den Heuvel-Eibrink, Princess Máxima Center, Utrecht, and Dutch Childhood Oncology Group Long-Term Effects After Childhood Cancer (LATER) Group, The Hague, the Netherlands; Jeanette F. Winther, Danish Cancer Society Research Center, Copenhagen, and Aarhus University, Aarhus, Denmark; Melissa M. Hudson, St Jude Children's Research Hospital, Memphis, TN; and Kevin C. Oeffinger, Duke University, Durham, NC
| | - Jarmila Kruseova
- Emily S. Tonorezos, Memorial Sloan Kettering Cancer Center, New York, NY; Dana Barnea, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel; Richard J. Cohn, Sydney Children's Hospital, and University of New South Wales Medicine, Sydney, New South Wales, Australia; Monica S. Cypriano, Grupo de Apoio ao Adolescente e Criança com Câncer (GRAACC)/Universidade Federal de São Paulo, São Paulo, Brazil; Brice C. Fresneau, Gustave Roussy, Université Paris-Saclay, Paris-Sud University, Centre for Research in Epidemiology and Population Health (CESP), and L'Institut National de la Santé et de la Recherche Médicale, Villejuif, France; Riccardo Haupt, Istituto Giannina Gaslini, Genoa, Italy; Lars Hjorth, Lund University, Skane University Hospital, Lund, Sweden; Yasushi Ishida, Ehime Prefectural Central Hospital, Matsuyama, Japan; Jarmila Kruseova, Charles University, Prague, Czech Republic; Claudia E. Kuehni, University of Bern, Bern, Switzerland; Purna A. Kurkure, Society for Rehabilitation of Crippled Children (SRCC) Children's Hospital, Indian Cancer Society, and Tata Memorial Hospital, Mumbai, India; Thorsten Langer, University Hospital, Luebeck, Germany; Paul C. Nathan, The Hospital for Sick Children, The University of Toronto, Toronto, Ontario, Canada; Jane E. Skeen, Starship Children's Hospital, Auckland, New Zealand; Roderick Skinner, Great North Children's Hospital, Newcastle upon Tyne Hospitals National Health Service Foundation Trust, and Newcastle University, Newcastle upon Tyne, United Kingdom; Nurdan Tacyildiz, Ankara University School of Medicine, Ankara, Turkey; Marry M. van den Heuvel-Eibrink, Princess Máxima Center, Utrecht, and Dutch Childhood Oncology Group Long-Term Effects After Childhood Cancer (LATER) Group, The Hague, the Netherlands; Jeanette F. Winther, Danish Cancer Society Research Center, Copenhagen, and Aarhus University, Aarhus, Denmark; Melissa M. Hudson, St Jude Children's Research Hospital, Memphis, TN; and Kevin C. Oeffinger, Duke University, Durham, NC
| | - Claudia E Kuehni
- Emily S. Tonorezos, Memorial Sloan Kettering Cancer Center, New York, NY; Dana Barnea, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel; Richard J. Cohn, Sydney Children's Hospital, and University of New South Wales Medicine, Sydney, New South Wales, Australia; Monica S. Cypriano, Grupo de Apoio ao Adolescente e Criança com Câncer (GRAACC)/Universidade Federal de São Paulo, São Paulo, Brazil; Brice C. Fresneau, Gustave Roussy, Université Paris-Saclay, Paris-Sud University, Centre for Research in Epidemiology and Population Health (CESP), and L'Institut National de la Santé et de la Recherche Médicale, Villejuif, France; Riccardo Haupt, Istituto Giannina Gaslini, Genoa, Italy; Lars Hjorth, Lund University, Skane University Hospital, Lund, Sweden; Yasushi Ishida, Ehime Prefectural Central Hospital, Matsuyama, Japan; Jarmila Kruseova, Charles University, Prague, Czech Republic; Claudia E. Kuehni, University of Bern, Bern, Switzerland; Purna A. Kurkure, Society for Rehabilitation of Crippled Children (SRCC) Children's Hospital, Indian Cancer Society, and Tata Memorial Hospital, Mumbai, India; Thorsten Langer, University Hospital, Luebeck, Germany; Paul C. Nathan, The Hospital for Sick Children, The University of Toronto, Toronto, Ontario, Canada; Jane E. Skeen, Starship Children's Hospital, Auckland, New Zealand; Roderick Skinner, Great North Children's Hospital, Newcastle upon Tyne Hospitals National Health Service Foundation Trust, and Newcastle University, Newcastle upon Tyne, United Kingdom; Nurdan Tacyildiz, Ankara University School of Medicine, Ankara, Turkey; Marry M. van den Heuvel-Eibrink, Princess Máxima Center, Utrecht, and Dutch Childhood Oncology Group Long-Term Effects After Childhood Cancer (LATER) Group, The Hague, the Netherlands; Jeanette F. Winther, Danish Cancer Society Research Center, Copenhagen, and Aarhus University, Aarhus, Denmark; Melissa M. Hudson, St Jude Children's Research Hospital, Memphis, TN; and Kevin C. Oeffinger, Duke University, Durham, NC
| | - Purna A Kurkure
- Emily S. Tonorezos, Memorial Sloan Kettering Cancer Center, New York, NY; Dana Barnea, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel; Richard J. Cohn, Sydney Children's Hospital, and University of New South Wales Medicine, Sydney, New South Wales, Australia; Monica S. Cypriano, Grupo de Apoio ao Adolescente e Criança com Câncer (GRAACC)/Universidade Federal de São Paulo, São Paulo, Brazil; Brice C. Fresneau, Gustave Roussy, Université Paris-Saclay, Paris-Sud University, Centre for Research in Epidemiology and Population Health (CESP), and L'Institut National de la Santé et de la Recherche Médicale, Villejuif, France; Riccardo Haupt, Istituto Giannina Gaslini, Genoa, Italy; Lars Hjorth, Lund University, Skane University Hospital, Lund, Sweden; Yasushi Ishida, Ehime Prefectural Central Hospital, Matsuyama, Japan; Jarmila Kruseova, Charles University, Prague, Czech Republic; Claudia E. Kuehni, University of Bern, Bern, Switzerland; Purna A. Kurkure, Society for Rehabilitation of Crippled Children (SRCC) Children's Hospital, Indian Cancer Society, and Tata Memorial Hospital, Mumbai, India; Thorsten Langer, University Hospital, Luebeck, Germany; Paul C. Nathan, The Hospital for Sick Children, The University of Toronto, Toronto, Ontario, Canada; Jane E. Skeen, Starship Children's Hospital, Auckland, New Zealand; Roderick Skinner, Great North Children's Hospital, Newcastle upon Tyne Hospitals National Health Service Foundation Trust, and Newcastle University, Newcastle upon Tyne, United Kingdom; Nurdan Tacyildiz, Ankara University School of Medicine, Ankara, Turkey; Marry M. van den Heuvel-Eibrink, Princess Máxima Center, Utrecht, and Dutch Childhood Oncology Group Long-Term Effects After Childhood Cancer (LATER) Group, The Hague, the Netherlands; Jeanette F. Winther, Danish Cancer Society Research Center, Copenhagen, and Aarhus University, Aarhus, Denmark; Melissa M. Hudson, St Jude Children's Research Hospital, Memphis, TN; and Kevin C. Oeffinger, Duke University, Durham, NC
| | - Thorsten Langer
- Emily S. Tonorezos, Memorial Sloan Kettering Cancer Center, New York, NY; Dana Barnea, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel; Richard J. Cohn, Sydney Children's Hospital, and University of New South Wales Medicine, Sydney, New South Wales, Australia; Monica S. Cypriano, Grupo de Apoio ao Adolescente e Criança com Câncer (GRAACC)/Universidade Federal de São Paulo, São Paulo, Brazil; Brice C. Fresneau, Gustave Roussy, Université Paris-Saclay, Paris-Sud University, Centre for Research in Epidemiology and Population Health (CESP), and L'Institut National de la Santé et de la Recherche Médicale, Villejuif, France; Riccardo Haupt, Istituto Giannina Gaslini, Genoa, Italy; Lars Hjorth, Lund University, Skane University Hospital, Lund, Sweden; Yasushi Ishida, Ehime Prefectural Central Hospital, Matsuyama, Japan; Jarmila Kruseova, Charles University, Prague, Czech Republic; Claudia E. Kuehni, University of Bern, Bern, Switzerland; Purna A. Kurkure, Society for Rehabilitation of Crippled Children (SRCC) Children's Hospital, Indian Cancer Society, and Tata Memorial Hospital, Mumbai, India; Thorsten Langer, University Hospital, Luebeck, Germany; Paul C. Nathan, The Hospital for Sick Children, The University of Toronto, Toronto, Ontario, Canada; Jane E. Skeen, Starship Children's Hospital, Auckland, New Zealand; Roderick Skinner, Great North Children's Hospital, Newcastle upon Tyne Hospitals National Health Service Foundation Trust, and Newcastle University, Newcastle upon Tyne, United Kingdom; Nurdan Tacyildiz, Ankara University School of Medicine, Ankara, Turkey; Marry M. van den Heuvel-Eibrink, Princess Máxima Center, Utrecht, and Dutch Childhood Oncology Group Long-Term Effects After Childhood Cancer (LATER) Group, The Hague, the Netherlands; Jeanette F. Winther, Danish Cancer Society Research Center, Copenhagen, and Aarhus University, Aarhus, Denmark; Melissa M. Hudson, St Jude Children's Research Hospital, Memphis, TN; and Kevin C. Oeffinger, Duke University, Durham, NC
| | - Paul C Nathan
- Emily S. Tonorezos, Memorial Sloan Kettering Cancer Center, New York, NY; Dana Barnea, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel; Richard J. Cohn, Sydney Children's Hospital, and University of New South Wales Medicine, Sydney, New South Wales, Australia; Monica S. Cypriano, Grupo de Apoio ao Adolescente e Criança com Câncer (GRAACC)/Universidade Federal de São Paulo, São Paulo, Brazil; Brice C. Fresneau, Gustave Roussy, Université Paris-Saclay, Paris-Sud University, Centre for Research in Epidemiology and Population Health (CESP), and L'Institut National de la Santé et de la Recherche Médicale, Villejuif, France; Riccardo Haupt, Istituto Giannina Gaslini, Genoa, Italy; Lars Hjorth, Lund University, Skane University Hospital, Lund, Sweden; Yasushi Ishida, Ehime Prefectural Central Hospital, Matsuyama, Japan; Jarmila Kruseova, Charles University, Prague, Czech Republic; Claudia E. Kuehni, University of Bern, Bern, Switzerland; Purna A. Kurkure, Society for Rehabilitation of Crippled Children (SRCC) Children's Hospital, Indian Cancer Society, and Tata Memorial Hospital, Mumbai, India; Thorsten Langer, University Hospital, Luebeck, Germany; Paul C. Nathan, The Hospital for Sick Children, The University of Toronto, Toronto, Ontario, Canada; Jane E. Skeen, Starship Children's Hospital, Auckland, New Zealand; Roderick Skinner, Great North Children's Hospital, Newcastle upon Tyne Hospitals National Health Service Foundation Trust, and Newcastle University, Newcastle upon Tyne, United Kingdom; Nurdan Tacyildiz, Ankara University School of Medicine, Ankara, Turkey; Marry M. van den Heuvel-Eibrink, Princess Máxima Center, Utrecht, and Dutch Childhood Oncology Group Long-Term Effects After Childhood Cancer (LATER) Group, The Hague, the Netherlands; Jeanette F. Winther, Danish Cancer Society Research Center, Copenhagen, and Aarhus University, Aarhus, Denmark; Melissa M. Hudson, St Jude Children's Research Hospital, Memphis, TN; and Kevin C. Oeffinger, Duke University, Durham, NC
| | - Jane E Skeen
- Emily S. Tonorezos, Memorial Sloan Kettering Cancer Center, New York, NY; Dana Barnea, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel; Richard J. Cohn, Sydney Children's Hospital, and University of New South Wales Medicine, Sydney, New South Wales, Australia; Monica S. Cypriano, Grupo de Apoio ao Adolescente e Criança com Câncer (GRAACC)/Universidade Federal de São Paulo, São Paulo, Brazil; Brice C. Fresneau, Gustave Roussy, Université Paris-Saclay, Paris-Sud University, Centre for Research in Epidemiology and Population Health (CESP), and L'Institut National de la Santé et de la Recherche Médicale, Villejuif, France; Riccardo Haupt, Istituto Giannina Gaslini, Genoa, Italy; Lars Hjorth, Lund University, Skane University Hospital, Lund, Sweden; Yasushi Ishida, Ehime Prefectural Central Hospital, Matsuyama, Japan; Jarmila Kruseova, Charles University, Prague, Czech Republic; Claudia E. Kuehni, University of Bern, Bern, Switzerland; Purna A. Kurkure, Society for Rehabilitation of Crippled Children (SRCC) Children's Hospital, Indian Cancer Society, and Tata Memorial Hospital, Mumbai, India; Thorsten Langer, University Hospital, Luebeck, Germany; Paul C. Nathan, The Hospital for Sick Children, The University of Toronto, Toronto, Ontario, Canada; Jane E. Skeen, Starship Children's Hospital, Auckland, New Zealand; Roderick Skinner, Great North Children's Hospital, Newcastle upon Tyne Hospitals National Health Service Foundation Trust, and Newcastle University, Newcastle upon Tyne, United Kingdom; Nurdan Tacyildiz, Ankara University School of Medicine, Ankara, Turkey; Marry M. van den Heuvel-Eibrink, Princess Máxima Center, Utrecht, and Dutch Childhood Oncology Group Long-Term Effects After Childhood Cancer (LATER) Group, The Hague, the Netherlands; Jeanette F. Winther, Danish Cancer Society Research Center, Copenhagen, and Aarhus University, Aarhus, Denmark; Melissa M. Hudson, St Jude Children's Research Hospital, Memphis, TN; and Kevin C. Oeffinger, Duke University, Durham, NC
| | - Roderick Skinner
- Emily S. Tonorezos, Memorial Sloan Kettering Cancer Center, New York, NY; Dana Barnea, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel; Richard J. Cohn, Sydney Children's Hospital, and University of New South Wales Medicine, Sydney, New South Wales, Australia; Monica S. Cypriano, Grupo de Apoio ao Adolescente e Criança com Câncer (GRAACC)/Universidade Federal de São Paulo, São Paulo, Brazil; Brice C. Fresneau, Gustave Roussy, Université Paris-Saclay, Paris-Sud University, Centre for Research in Epidemiology and Population Health (CESP), and L'Institut National de la Santé et de la Recherche Médicale, Villejuif, France; Riccardo Haupt, Istituto Giannina Gaslini, Genoa, Italy; Lars Hjorth, Lund University, Skane University Hospital, Lund, Sweden; Yasushi Ishida, Ehime Prefectural Central Hospital, Matsuyama, Japan; Jarmila Kruseova, Charles University, Prague, Czech Republic; Claudia E. Kuehni, University of Bern, Bern, Switzerland; Purna A. Kurkure, Society for Rehabilitation of Crippled Children (SRCC) Children's Hospital, Indian Cancer Society, and Tata Memorial Hospital, Mumbai, India; Thorsten Langer, University Hospital, Luebeck, Germany; Paul C. Nathan, The Hospital for Sick Children, The University of Toronto, Toronto, Ontario, Canada; Jane E. Skeen, Starship Children's Hospital, Auckland, New Zealand; Roderick Skinner, Great North Children's Hospital, Newcastle upon Tyne Hospitals National Health Service Foundation Trust, and Newcastle University, Newcastle upon Tyne, United Kingdom; Nurdan Tacyildiz, Ankara University School of Medicine, Ankara, Turkey; Marry M. van den Heuvel-Eibrink, Princess Máxima Center, Utrecht, and Dutch Childhood Oncology Group Long-Term Effects After Childhood Cancer (LATER) Group, The Hague, the Netherlands; Jeanette F. Winther, Danish Cancer Society Research Center, Copenhagen, and Aarhus University, Aarhus, Denmark; Melissa M. Hudson, St Jude Children's Research Hospital, Memphis, TN; and Kevin C. Oeffinger, Duke University, Durham, NC
| | - Nurdan Tacyildiz
- Emily S. Tonorezos, Memorial Sloan Kettering Cancer Center, New York, NY; Dana Barnea, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel; Richard J. Cohn, Sydney Children's Hospital, and University of New South Wales Medicine, Sydney, New South Wales, Australia; Monica S. Cypriano, Grupo de Apoio ao Adolescente e Criança com Câncer (GRAACC)/Universidade Federal de São Paulo, São Paulo, Brazil; Brice C. Fresneau, Gustave Roussy, Université Paris-Saclay, Paris-Sud University, Centre for Research in Epidemiology and Population Health (CESP), and L'Institut National de la Santé et de la Recherche Médicale, Villejuif, France; Riccardo Haupt, Istituto Giannina Gaslini, Genoa, Italy; Lars Hjorth, Lund University, Skane University Hospital, Lund, Sweden; Yasushi Ishida, Ehime Prefectural Central Hospital, Matsuyama, Japan; Jarmila Kruseova, Charles University, Prague, Czech Republic; Claudia E. Kuehni, University of Bern, Bern, Switzerland; Purna A. Kurkure, Society for Rehabilitation of Crippled Children (SRCC) Children's Hospital, Indian Cancer Society, and Tata Memorial Hospital, Mumbai, India; Thorsten Langer, University Hospital, Luebeck, Germany; Paul C. Nathan, The Hospital for Sick Children, The University of Toronto, Toronto, Ontario, Canada; Jane E. Skeen, Starship Children's Hospital, Auckland, New Zealand; Roderick Skinner, Great North Children's Hospital, Newcastle upon Tyne Hospitals National Health Service Foundation Trust, and Newcastle University, Newcastle upon Tyne, United Kingdom; Nurdan Tacyildiz, Ankara University School of Medicine, Ankara, Turkey; Marry M. van den Heuvel-Eibrink, Princess Máxima Center, Utrecht, and Dutch Childhood Oncology Group Long-Term Effects After Childhood Cancer (LATER) Group, The Hague, the Netherlands; Jeanette F. Winther, Danish Cancer Society Research Center, Copenhagen, and Aarhus University, Aarhus, Denmark; Melissa M. Hudson, St Jude Children's Research Hospital, Memphis, TN; and Kevin C. Oeffinger, Duke University, Durham, NC
| | - Marry M van den Heuvel-Eibrink
- Emily S. Tonorezos, Memorial Sloan Kettering Cancer Center, New York, NY; Dana Barnea, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel; Richard J. Cohn, Sydney Children's Hospital, and University of New South Wales Medicine, Sydney, New South Wales, Australia; Monica S. Cypriano, Grupo de Apoio ao Adolescente e Criança com Câncer (GRAACC)/Universidade Federal de São Paulo, São Paulo, Brazil; Brice C. Fresneau, Gustave Roussy, Université Paris-Saclay, Paris-Sud University, Centre for Research in Epidemiology and Population Health (CESP), and L'Institut National de la Santé et de la Recherche Médicale, Villejuif, France; Riccardo Haupt, Istituto Giannina Gaslini, Genoa, Italy; Lars Hjorth, Lund University, Skane University Hospital, Lund, Sweden; Yasushi Ishida, Ehime Prefectural Central Hospital, Matsuyama, Japan; Jarmila Kruseova, Charles University, Prague, Czech Republic; Claudia E. Kuehni, University of Bern, Bern, Switzerland; Purna A. Kurkure, Society for Rehabilitation of Crippled Children (SRCC) Children's Hospital, Indian Cancer Society, and Tata Memorial Hospital, Mumbai, India; Thorsten Langer, University Hospital, Luebeck, Germany; Paul C. Nathan, The Hospital for Sick Children, The University of Toronto, Toronto, Ontario, Canada; Jane E. Skeen, Starship Children's Hospital, Auckland, New Zealand; Roderick Skinner, Great North Children's Hospital, Newcastle upon Tyne Hospitals National Health Service Foundation Trust, and Newcastle University, Newcastle upon Tyne, United Kingdom; Nurdan Tacyildiz, Ankara University School of Medicine, Ankara, Turkey; Marry M. van den Heuvel-Eibrink, Princess Máxima Center, Utrecht, and Dutch Childhood Oncology Group Long-Term Effects After Childhood Cancer (LATER) Group, The Hague, the Netherlands; Jeanette F. Winther, Danish Cancer Society Research Center, Copenhagen, and Aarhus University, Aarhus, Denmark; Melissa M. Hudson, St Jude Children's Research Hospital, Memphis, TN; and Kevin C. Oeffinger, Duke University, Durham, NC
| | - Jeanette F Winther
- Emily S. Tonorezos, Memorial Sloan Kettering Cancer Center, New York, NY; Dana Barnea, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel; Richard J. Cohn, Sydney Children's Hospital, and University of New South Wales Medicine, Sydney, New South Wales, Australia; Monica S. Cypriano, Grupo de Apoio ao Adolescente e Criança com Câncer (GRAACC)/Universidade Federal de São Paulo, São Paulo, Brazil; Brice C. Fresneau, Gustave Roussy, Université Paris-Saclay, Paris-Sud University, Centre for Research in Epidemiology and Population Health (CESP), and L'Institut National de la Santé et de la Recherche Médicale, Villejuif, France; Riccardo Haupt, Istituto Giannina Gaslini, Genoa, Italy; Lars Hjorth, Lund University, Skane University Hospital, Lund, Sweden; Yasushi Ishida, Ehime Prefectural Central Hospital, Matsuyama, Japan; Jarmila Kruseova, Charles University, Prague, Czech Republic; Claudia E. Kuehni, University of Bern, Bern, Switzerland; Purna A. Kurkure, Society for Rehabilitation of Crippled Children (SRCC) Children's Hospital, Indian Cancer Society, and Tata Memorial Hospital, Mumbai, India; Thorsten Langer, University Hospital, Luebeck, Germany; Paul C. Nathan, The Hospital for Sick Children, The University of Toronto, Toronto, Ontario, Canada; Jane E. Skeen, Starship Children's Hospital, Auckland, New Zealand; Roderick Skinner, Great North Children's Hospital, Newcastle upon Tyne Hospitals National Health Service Foundation Trust, and Newcastle University, Newcastle upon Tyne, United Kingdom; Nurdan Tacyildiz, Ankara University School of Medicine, Ankara, Turkey; Marry M. van den Heuvel-Eibrink, Princess Máxima Center, Utrecht, and Dutch Childhood Oncology Group Long-Term Effects After Childhood Cancer (LATER) Group, The Hague, the Netherlands; Jeanette F. Winther, Danish Cancer Society Research Center, Copenhagen, and Aarhus University, Aarhus, Denmark; Melissa M. Hudson, St Jude Children's Research Hospital, Memphis, TN; and Kevin C. Oeffinger, Duke University, Durham, NC
| | - Melissa M Hudson
- Emily S. Tonorezos, Memorial Sloan Kettering Cancer Center, New York, NY; Dana Barnea, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel; Richard J. Cohn, Sydney Children's Hospital, and University of New South Wales Medicine, Sydney, New South Wales, Australia; Monica S. Cypriano, Grupo de Apoio ao Adolescente e Criança com Câncer (GRAACC)/Universidade Federal de São Paulo, São Paulo, Brazil; Brice C. Fresneau, Gustave Roussy, Université Paris-Saclay, Paris-Sud University, Centre for Research in Epidemiology and Population Health (CESP), and L'Institut National de la Santé et de la Recherche Médicale, Villejuif, France; Riccardo Haupt, Istituto Giannina Gaslini, Genoa, Italy; Lars Hjorth, Lund University, Skane University Hospital, Lund, Sweden; Yasushi Ishida, Ehime Prefectural Central Hospital, Matsuyama, Japan; Jarmila Kruseova, Charles University, Prague, Czech Republic; Claudia E. Kuehni, University of Bern, Bern, Switzerland; Purna A. Kurkure, Society for Rehabilitation of Crippled Children (SRCC) Children's Hospital, Indian Cancer Society, and Tata Memorial Hospital, Mumbai, India; Thorsten Langer, University Hospital, Luebeck, Germany; Paul C. Nathan, The Hospital for Sick Children, The University of Toronto, Toronto, Ontario, Canada; Jane E. Skeen, Starship Children's Hospital, Auckland, New Zealand; Roderick Skinner, Great North Children's Hospital, Newcastle upon Tyne Hospitals National Health Service Foundation Trust, and Newcastle University, Newcastle upon Tyne, United Kingdom; Nurdan Tacyildiz, Ankara University School of Medicine, Ankara, Turkey; Marry M. van den Heuvel-Eibrink, Princess Máxima Center, Utrecht, and Dutch Childhood Oncology Group Long-Term Effects After Childhood Cancer (LATER) Group, The Hague, the Netherlands; Jeanette F. Winther, Danish Cancer Society Research Center, Copenhagen, and Aarhus University, Aarhus, Denmark; Melissa M. Hudson, St Jude Children's Research Hospital, Memphis, TN; and Kevin C. Oeffinger, Duke University, Durham, NC
| | - Kevin C Oeffinger
- Emily S. Tonorezos, Memorial Sloan Kettering Cancer Center, New York, NY; Dana Barnea, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel; Richard J. Cohn, Sydney Children's Hospital, and University of New South Wales Medicine, Sydney, New South Wales, Australia; Monica S. Cypriano, Grupo de Apoio ao Adolescente e Criança com Câncer (GRAACC)/Universidade Federal de São Paulo, São Paulo, Brazil; Brice C. Fresneau, Gustave Roussy, Université Paris-Saclay, Paris-Sud University, Centre for Research in Epidemiology and Population Health (CESP), and L'Institut National de la Santé et de la Recherche Médicale, Villejuif, France; Riccardo Haupt, Istituto Giannina Gaslini, Genoa, Italy; Lars Hjorth, Lund University, Skane University Hospital, Lund, Sweden; Yasushi Ishida, Ehime Prefectural Central Hospital, Matsuyama, Japan; Jarmila Kruseova, Charles University, Prague, Czech Republic; Claudia E. Kuehni, University of Bern, Bern, Switzerland; Purna A. Kurkure, Society for Rehabilitation of Crippled Children (SRCC) Children's Hospital, Indian Cancer Society, and Tata Memorial Hospital, Mumbai, India; Thorsten Langer, University Hospital, Luebeck, Germany; Paul C. Nathan, The Hospital for Sick Children, The University of Toronto, Toronto, Ontario, Canada; Jane E. Skeen, Starship Children's Hospital, Auckland, New Zealand; Roderick Skinner, Great North Children's Hospital, Newcastle upon Tyne Hospitals National Health Service Foundation Trust, and Newcastle University, Newcastle upon Tyne, United Kingdom; Nurdan Tacyildiz, Ankara University School of Medicine, Ankara, Turkey; Marry M. van den Heuvel-Eibrink, Princess Máxima Center, Utrecht, and Dutch Childhood Oncology Group Long-Term Effects After Childhood Cancer (LATER) Group, The Hague, the Netherlands; Jeanette F. Winther, Danish Cancer Society Research Center, Copenhagen, and Aarhus University, Aarhus, Denmark; Melissa M. Hudson, St Jude Children's Research Hospital, Memphis, TN; and Kevin C. Oeffinger, Duke University, Durham, NC
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Bierig SM, Arnold A, Einbinder LC, Armbrecht E, Burroughs T. Cardiovascular Ultrasound Combined With Non-invasive Screening for the Detection of Undiagnosed Cardiovascular Disease: A Literature Review. JOURNAL OF DIAGNOSTIC MEDICAL SONOGRAPHY 2018. [DOI: 10.1177/8756479317737764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Non-invasive screenings have been widely utilized in the United States and worldwide to provide early identification of cardiovascular disease, allowing for earlier diagnosis and treatment. Screening sonography detects valve disease, cardiac dysfunction, and carotid disease in 5% to 20% of the population. This review discusses the current data regarding cardiovascular screening, the methodologies, and the resources required for performance of screenings. Cardiac and carotid sonography is highly accurate and discovers cardiovascular diseases that impact quality of life and risk of future events. Screenings are performed in a variety of settings and accuracy depends on the quality of personnel performing the non-invasive testing, the equipment utilized, and the personnel interpreting the studies. Despite the potential benefit for disease detection, population screening to detect cardiovascular disease is not widely supported by national organizations due to the theoretical cost of further testing and lack of cost versus benefit data. Additional studies are necessary to compare costs and benefits of non-invasive cardiovascular screening in the community setting.
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Affiliation(s)
| | | | | | - Eric Armbrecht
- Saint Louis University Center for Outcomes Research, Saint Louis, MO, USA
| | - Thomas Burroughs
- Saint Louis University Center for Outcomes Research, Saint Louis, MO, USA
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49
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Dixon SB, Bjornard KL, Alberts NM, Armstrong GT, Brinkman TM, Chemaitilly W, Ehrhardt MJ, Fernandez-Pineda I, Force LM, Gibson TM, Green DM, Howell CR, Kaste SC, Kirchhoff A, Klosky JL, Krull KR, Lucas JT, Mulrooney DA, Ness KK, Wilson CL, Yasui Y, Robison LL, Hudson MM. Factors influencing risk-based care of the childhood cancer survivor in the 21st century. CA Cancer J Clin 2018; 68:133-152. [PMID: 29377070 PMCID: PMC8893118 DOI: 10.3322/caac.21445] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2017] [Revised: 12/12/2017] [Accepted: 12/12/2017] [Indexed: 12/30/2022] Open
Abstract
The population of adult survivors of childhood cancer continues to grow as survival rates improve. Although it is well established that these survivors experience various complications and comorbidities related to their malignancy and treatment, this risk is modified by many factors that are not directly linked to their cancer history. Research evaluating the influence of patient-specific demographic and genetic factors, premorbid and comorbid conditions, health behaviors, and aging has identified additional risk factors that influence cancer treatment-related toxicity and possible targets for intervention in this population. Furthermore, although current long-term follow-up guidelines comprehensively address specific therapy-related risks and provide screening recommendations, the risk profile of the population continues to evolve with ongoing modification of treatment strategies and the emergence of novel therapeutics. To address the multifactorial modifiers of cancer treatment-related health risk and evolving treatment approaches, a patient-centered and risk-adapted approach to care that often requires a multidisciplinary team approach, including medical and behavioral providers, is necessary for this population. CA Cancer J Clin 2018;68:133-152. © 2018 American Cancer Society.
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Affiliation(s)
- Stephanie B Dixon
- Department of Oncology, St. Jude Children’s Research Hospital, Memphis, TN
| | - Kari L Bjornard
- Department of Oncology, St. Jude Children’s Research Hospital, Memphis, TN
| | - Nicole M Alberts
- Department of Psychology, St. Jude Children’s Research Hospital, Memphis, TN
| | - Gregory T Armstrong
- Department of Epidemiology and Cancer Control, St. Jude Children’s Research Hospital, Memphis, TN
| | - Tara M Brinkman
- Department of Psychology, St. Jude Children’s Research Hospital, Memphis, TN
- Department of Epidemiology and Cancer Control, St. Jude Children’s Research Hospital, Memphis, TN
| | - Wassim Chemaitilly
- Department of Epidemiology and Cancer Control, St. Jude Children’s Research Hospital, Memphis, TN
- Department of Pediatric Medicine – Division of Endocrinology, St. Jude Children’s Research Hospital, Memphis, TN
| | - Matthew J Ehrhardt
- Department of Oncology, St. Jude Children’s Research Hospital, Memphis, TN
- Department of Epidemiology and Cancer Control, St. Jude Children’s Research Hospital, Memphis, TN
| | | | - Lisa M Force
- Department of Oncology, St. Jude Children’s Research Hospital, Memphis, TN
| | - Todd M Gibson
- Department of Epidemiology and Cancer Control, St. Jude Children’s Research Hospital, Memphis, TN
| | - Daniel M Green
- Department of Oncology, St. Jude Children’s Research Hospital, Memphis, TN
- Department of Epidemiology and Cancer Control, St. Jude Children’s Research Hospital, Memphis, TN
| | - Carrie R Howell
- Department of Epidemiology and Cancer Control, St. Jude Children’s Research Hospital, Memphis, TN
| | - Sue C Kaste
- Department of Oncology, St. Jude Children’s Research Hospital, Memphis, TN
- Department of Diagnostic Imaging, St. Jude Children’s Research Hospital, Memphis, TN
- Department of Radiology, University of Tennessee Health Science Center, Memphis, TN
| | - Anne Kirchhoff
- Department of Pediatrics and Huntsman Cancer Institute, University of Utah, Salt Lake City, UT
| | - James L Klosky
- Department of Psychology, St. Jude Children’s Research Hospital, Memphis, TN
| | - Kevin R Krull
- Department of Psychology, St. Jude Children’s Research Hospital, Memphis, TN
- Department of Epidemiology and Cancer Control, St. Jude Children’s Research Hospital, Memphis, TN
| | - John T Lucas
- Department of Radiation Oncology, St. Jude Children’s Research Hospital, Memphis, TN
| | - Daniel A Mulrooney
- Department of Oncology, St. Jude Children’s Research Hospital, Memphis, TN
- Department of Epidemiology and Cancer Control, St. Jude Children’s Research Hospital, Memphis, TN
| | - Kirsten K Ness
- Department of Epidemiology and Cancer Control, St. Jude Children’s Research Hospital, Memphis, TN
| | - Carmen L Wilson
- Department of Epidemiology and Cancer Control, St. Jude Children’s Research Hospital, Memphis, TN
| | - Yutaka Yasui
- Department of Epidemiology and Cancer Control, St. Jude Children’s Research Hospital, Memphis, TN
| | - Leslie L Robison
- Department of Epidemiology and Cancer Control, St. Jude Children’s Research Hospital, Memphis, TN
| | - Melissa M Hudson
- Department of Oncology, St. Jude Children’s Research Hospital, Memphis, TN
- Department of Epidemiology and Cancer Control, St. Jude Children’s Research Hospital, Memphis, TN
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50
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Abstract
Survivors of childhood and adult-onset cancer are at lifelong risk for the development of late effects of treatment that can lead to serious morbidity and premature mortality. Regular long-term follow-up aiming for prevention, early detection and intervention of late effects can preserve or improve health. The heterogeneous and often serious character of late effects emphasizes the need for specialized cancer survivorship care clinics. Multidisciplinary cancer survivorship care requires a coordinated and well integrated health care environment for risk based screening and intervention. In addition survivors engagement and adherence to the recommendations are also important elements. We developed an innovative model for integrated care for cancer survivors, the "Personalized Cancer Survivorship Care Model", that is being used in our clinic. This model comprises 1. Personalized follow-up care according to the principles of Person Centered Care, aiming to empower survivors and to support self management, and 2. Organization according to a multidisciplinary and risk based approach. The concept of person centered care is based on three components: initiating, integrating and safeguarding the partnership with the patient. This model has been developed as a universal model of care that will work for all cancer survivors in different health care systems. It could be used for studies to improve self efficacy and the cost-effectiveness of cancer survivorship care.
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